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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198200507
Report Date: 06/12/2024
Date Signed: 06/12/2024 11:12:40 AM

Document Has Been Signed on 06/12/2024 11:12 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:ULTIMATE CARE IIIFACILITY NUMBER:
198200507
ADMINISTRATOR/
DIRECTOR:		DAVIS, CLINESE J.FACILITY TYPE:
735
ADDRESS:508 LOMA VISTA STREETTELEPHONE:
(310) 640-7740
CITY:EL SEGUNDOSTATE: CAZIP CODE:
90245
CAPACITY: 4CENSUS: 2DATE:
06/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:42 AM
MET WITH: Deborah LewisTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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On 06/12/2024 at 8:42 AM, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced Required – 1 Year Inspection to the above-named facility and met with House Manager Deborah Lewis. LPA explained the purpose of the visit and were accompanied by House Manager inside and outside the facility during this inspection.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: 4 bedrooms, 2 bathrooms, family room, living room, kitchen, dining room/office, indoor and outdoor activity area, and laundry room in the detached garage.

The facility is licensed to operate for (4) developmentally disabled or Mentally Ill adults ages 18 through 59.

Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises.

Client’s bedrooms were checked. Mattresses were in good condition, adequate lighting, plenty of dresser and closet space observed. Walls and floors were clean and in good condition. Comforters, bed linen, bath towels and mattress protectors were adequately stocked. Bathroom toilets and water faucets worked properly. Adequate lighting and toiletries accessible to clients. LPA Cloyd tested hot water temperature and it measured 109.2 degrees Fahrenheit.

LPA observed supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days.



LPA observed that Medications were safe, locked and inaccessible. All medications observed were labeled and maintained in compliance with label instructions and State and Federal law. First aid kit is fully stocked with manual. Smoke and carbon monoxide detectors were in compliance and operational. Continue to LIC809-C.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE: DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/12/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: ULTIMATE CARE III
FACILITY NUMBER: 198200507
VISIT DATE: 06/12/2024
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Five (5) staff records were reviewed, 5 out of 5 staff records had required criminal record clearances or criminal record exemptions. Two staff members were interviewed.

Three (3) client records were reviewed and, 3 out of 3 client records had Admission Agreements, Medical Assessments, IPPs. Two client medications were reviewed.

No deficiencies cited.

An exit interview was conducted, technical assistance provided, and a copy of this report was discussed and left with the House Manager.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024
LIC809 (FAS) - (06/04)
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