<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198202552
Report Date: 10/26/2023
Date Signed: 10/26/2023 12:10:37 PM

Document Has Been Signed on 10/26/2023 12:10 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
EL SEGUNDO ASC, 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: 3DATE:
10/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Deborah LewisTIME COMPLETED:
12:05 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced Annual/Required visit with the primary focus on Infection Control measures and using the new CARE Inspection Tool. Upon arrival at the facility, LPA Bunker conducted a risk assessment. Based on the assessment, the facility is clear of COVID-19 infection. LPA Bunker was properly screened for COVID-19 symptoms and temperature was checked. LPA Bunker met with House Manager Deborah Lewis and explained the purpose of today's Annual Inspection. LPA verified that the facility has an approved Mitigation Plan Report and Infection Control Report. There are currently three (3), Westside Regional Center Adult Residential Care Facility (ARF) consumers in placement. The facility's annual fees are current.

The following Domains will be observed and reviewed: Infection Control, Physical Plant and Environmental Safety, Operational Requirements, Staffing, Personnel Records-Training, Clients Rights-Information, Clients Records-Incident Reports, Food Service, Health-Related Services, Incidental Medical Servces, Disaster Preparedness, and Emergency Intervention,. "LPA Bunker will be using this tool and methods that have been developed to improve the efficiency and accuracy of the Department of Social Services facility inspections.

The facility is a single story-family home located in a residential neighborhood. House Manager Ms. Lewis and LPA Bunker toured the facility which consisted of the following: Living room, dining area, family room, kitchen, 5 bedrooms, 3 bathrooms, laundry area, shaded area, indoor/outdoor activity areas, and a two car detached garage. The front and back yard landscape is in good condition at the time of the visit.
See continued LIC809-C on page 2
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE: DATE: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/26/2023
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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: ULTIMATE CARE IV
FACILITY NUMBER: 198202552
VISIT DATE: 10/26/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued LIC809-C page #2

During the tour, LPA observed the facility’s infection control practices. LPA observed sanitizer, visitor log, and thermometer at the facility entrance. Logs of daily COVID-19 screening and temperature checks of clients and staff were available and updated. PPE supplies are readily available to staff, and an additional supply of PPE was observed. Sufficient liquid soap, paper goods, cleaning, and disinfecting supplies were observed. LPA observed staff wearing a face covering and social distancing.

Documents were posted as mandated on the bulletin board wall in the dining area. 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. The first aid kit is fully stocked with a manual, the hot water temperature was measured at 108.4 degrees Fahrenheit, the telephones are working, smoke and carbon monoxide detectors were in compliance, fire extinguishers are fully charged, medications were centrally stored and properly locked in the family room file cabinet and records are current, ample supply of perishable and nonperishable food, adequate linen supply, fire/emergency drill conducted on October 17, 2023. No firearms on the premises, the client's bedroom windows had no sliding window lock with thumbscrew, all exit doors were in compliance, covered trash cans, and no bodies of water were present. Hazardous items are inaccessible to clients, the yard is free of debris and hazards. The House Manager states staff was given training on dependent adult and elder abuse reporting.

There were no deficiencies cited. LPA Bunker provided House Manager Deborah Lewis with copies of the LIC809, LIC809-C, LIC858, and LIC859 documents.

Exit interview conducted.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2