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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198202552
Report Date: 10/10/2024
Date Signed: 10/11/2024 08:29:39 AM

Document Has Been Signed on 10/11/2024 08:29 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 IVFACILITY NUMBER:
198202552
ADMINISTRATOR/
DIRECTOR:		DAVIS, CLINESE J.FACILITY TYPE:
735
ADDRESS:10921 CASMIR AVETELEPHONE:
(323) 755-6967
CITY:INGLEWOODSTATE: CAZIP CODE:
90303
CAPACITY: 4CENSUS: 2DATE:
10/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:33 PM
MET WITH:Uzochukwu ObiTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced annual/required visit with the primary focus on infection control measures and the use of 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 staff member Uzochukwu Obi and explained the purpose of today's Annual Inspection. LPA verified that the facility has an approved Mitigation Plan and an Infection Control Report. There are currently two (2), Westside Regional Center Adult Residential Care Facility (ARF) consumers in placement. The facility's annual fees are current.

The facility is a single-family home located in a residential neighborhood. Staff Uzochukwu Obi and LPA Bunker toured the facility which consisted of the following: Living room, dining area, family room, kitchen, 4 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.

Due to time constraints, LPA Bunker will return at a later date to complete the visit.

There were no deficiencies cited.

An exit interview was conducted.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE: DATE: 10/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2024
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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