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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198202552
Report Date: 03/15/2022
Date Signed: 03/15/2022 05:16:25 PM

Document Has Been Signed on 03/15/2022 05:16 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
MONTERY 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:
03/15/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:34 PM
MET WITH:Uila SekonaTIME COMPLETED:
05:15 PM
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Licensing Program Analyst (LPA) Stephanie Cifuentes conducted a Case Management visit in relation to incident report regarding client#1 that was reported via fax to CCL on 3/14/2022. LPA met with house manager Uila Sekona and discussed the purpose of the visit.

During todays’ visit LPA reviewed the file of client #1, interviewed manager and staff 1 (S1). Per manager 3/13/2022 client #1 was standing in driveway then proceeded to walk into the street, where they were struck by car.

LPA requested for house manager Uila to fax the following documents to licensing as facility has no copy machine: IPP, needs and services appraisal, facility file for S1.

No deficiencies will be cited at this time, additional investigation is required which includes analysis of the records obtained and follow up interviews.

Exit interview held and a copy of report provided to Manager Uila Sekona

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Stephanie Cifuentes
LICENSING EVALUATOR SIGNATURE: DATE: 03/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/15/2022
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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