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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198202552
Report Date: 10/11/2021
Date Signed: 10/21/2021 02:14:23 PM

Document Has Been Signed on 10/21/2021 02:14 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:ULTIMATE CARE IVFACILITY NUMBER:
198202552
ADMINISTRATOR:DAVIS, CLINESE J.FACILITY TYPE:
735
ADDRESS:10921 CASMIR AVETELEPHONE:
(323) 755-6967
CITY:INGLEWOODSTATE: CAZIP CODE:
90303
CAPACITY: 4CENSUS: 4DATE:
10/11/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Uila SekonaTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced Required - 1 Year Annual visit. The primary focus is on the Infection Control measures using the new CARE Inspection Tools. Upon arrival at the facility, LPA Bunker called the facility and spoke to Licensee Collette Johnson Ramirez via telephone to conduct a risk assessment. Based on the assessment, the facility is clear of COVID-19 infection.

LPA Bunker met with House Manager Uila Sekona and explained the purpose of today's visit. LPA Bunker was properly screened for COVID-19 symptoms and temperature was checked. LPA observed a sanitizing station at the facility back entrance; visitors log with COVID-19 screening and temperature log, and records of daily COVID-19 screening and temperature checks of residents and staff. PPE supplies are readily available to staff, and an additional over 90-day supply of PPE is stored in the storage closet; sufficient paper, cleaning, and disinfecting supplies were observed. LPA reviewed the facility’s surveillance testing records. LPA verified that the facility has an approved Mitigation Plan Report. Ms. Sekona stated staff and clients are fully vaccinated. Staff and clients have completed the N95 fit testing requirement. The facility is licensed for four (4) ambulatory clients.
House Manager Uila Sekona and LPA Bunker toured the entire facility inside and outside grounds. The facility is a single-story family home located in a residential neighborhood. The facility consisted of the following: Living room, family room, dining area, kitchen, five (5) bedrooms, three (3) bathrooms, laundry area in kitchen, indoor/outdoor activity area, shaded area, detached two (2) car garage, front and back yard landscape is in good condition at the time of visit. Documents were posted as mandated. During the tour, LPA Bunker observed the facility’s infection control practices. Bedrooms #1-3 are designated as client's rooms, bedroom #4 is designated as the COVID-19 isolation quarantine room and bedroom #5 is designated for living in staff.

See continued LIC809-C on page #2
SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE: DATE: 10/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/11/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: ULTIMATE CARE IV
FACILITY NUMBER: 198202552
VISIT DATE: 10/11/2021
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Continued LIC809-C page #2

The following Title 22 regulated areas were audited and found to be in compliance: Bedrooms contain the required furniture. The client's bedrooms were inspected for, safety, privacy, and comfort. The living areas are clean, bathrooms are clean and operational. First aid kit is fully stocked with manual, hot water temperature 110.7 degrees Fahrenheit, working telephone, smoke and carbon monoxide detectors were in compliance, fire extinguishers are fully charged, records medications is centrally stored and properly locked in the kitchen, adequate linen supply, ample supply of perishable and nonperishable food. No firearms on the premises, resident's bedroom windows have no sliding window locks with thumbscrews, all exit doors were in compliance, covered trash cans, and no bodies of water present. Hazardous items are inaccessible to clients, the yard is free of debris and hazards.

House Manager states staff was given training on dependent adult and elder abuse reporting.

There were no deficiencies cited.

Exit interview conducted.
SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2021
LIC809 (FAS) - (06/04)
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