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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198202552
Report Date: 12/29/2022
Date Signed: 01/09/2023 10:39:26 AM

Document Has Been Signed on 01/09/2023 10:39 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, 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:
12/29/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:12 PM
MET WITH:TIME COMPLETED:
04:00 PM
NARRATIVE
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On 12/29/2022 Licensing Program Analyst (LPA) Wendy Gibbs conducted a subsequent Case Management visit to issue the final report regarding an incident that occurred on 3/13/2022. LPA met with staff Clinese Davis to discuss the purpose of the visit and was granted entry to the facility.

On 3/15/2022 the department conducted an onsite case management visit to investigate and gather additional information regarding the injury of client 1 (C1) upon receiving an incident report from the facility dated 3/14/2022. Facility reported that (C1) walked into the street and was struck by a car, resulting in a hospitalization for a fracture in the right knee area.

The department conducted an investigation into the incident which consisted of a review the following documents: of Physicians Report, annual behavioral assessment and Behavioral Intervention Plan (BIP), Individualized Program Plan (IPP), medication list, discharge summary, hospital records, traffic collision report, staff files, staff schedule, staff training and regional center investigative report. The department’s investigation also consisted of interviews with facility clients and staff conducted by both Department of Social Services, Community Care Licensing Division Investigations Branch Investigator Lorraine Patterson and LPA Stephanie Cifuentes.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE: DATE: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/29/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: ULTIMATE CARE IV
FACILITY NUMBER: 198202552
VISIT DATE: 12/29/2022
NARRATIVE
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The investigation revealed the following: From interviews it was found that facility clients were on an outing to another facility and preparing to return home around 7:20pm. As staff 1 (S1) was escorting client 1 (C1) down the driveway, client 2 (C2), who was standing at the top of the stairs in front of facility doorway, began to have a behavior. S1 let go of C1 to assist C2, asking C1 to stay in place. As S1 assisted C2, C1 continued to walk down driveway and into the street, where they were stuck by a car. 911 was called and C1 was taken to the hospital. Per review of records and interviews it was determined (S1) was the only staff member escorting the four clients from the facility to the vehicle, which was parked across the street. The facilities ratio is three staff to four clients. Review of the staff schedule shows only two staff were scheduled to work at facility on day of incident, and by the time the incident occurred, only one facility staff was on shift to work with clients. In addition, per interviews, facility transportation should have been parked in driveway or at curb in front of facility as per staff training. Review of medical records shows that C1’s discharge diagnosis was a proximal fibular facture and mildly displaced anterior right fifth rib fracture.

Based on observations, interviews and record review(s), the preponderance of evidence standard has been met. Records and interviews indicate there was a lack of care/supervision that led to neglect of client and hospitalization for two fractures. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 809D.

An Immediate Civil Penalty will be issued today in the amount of $500.00 due to resident sustaining injury/illness while under the facility care.

At this time, an enhanced civil penalty determination is pending in reference to Health & Safety Code 1569.49(e)(1)(A) “Serious Bodily Injury” as defined in Section 243 of the Penal Code that states, a serious physical condition, including, but not limited to, the following: loss of consciousness; concussion; bone fracture; protracted loss or impairment of any bodily member or organ; a wound requiring extensive suturing; and serious disfigurement.”
An exit interview was conducted and copy of the Report and Appeal Rights were provided to Clinese Davis.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/09/2023 10:39 AM - It Cannot Be Edited


Created By: Wendy Gibbs On 12/29/2022 at 02:19 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ULTIMATE CARE IV
FACILITY NUMBER: 198202552

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
12/30/2022
Section Cited
CCR
80072(a)(2)

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Personal Rights--Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following…To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs
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Licensee/Administrator will review Title 22 Sec. 80072(a)(2) and will provide to LPA a written statement as proof that this section was reviewed and will comply by POC due date.
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This requirement is not met as evidenced by:
Based on interview and review of records, C1 was hit by a car and sustained fractures. This violation poses a potential health and safety risk to the clients in care.
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**Immediate Civil Penalties is being assessed in the amount of $500.00. **
Deficiency Dismissed
Type B
01/12/2023
Section Cited
CCR85065.5(a)(1)

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Day Staff-Client Ratio
For Regional Center clients, staffing shall be maintained as specified by the Regional Center but no less than one direct care staff to three such clients.
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Licensee/Administrator will develop a written plan on how they will meet facilities staffing ratios as required by regional center and
submit it in writing to LPA by POC due date.
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This requirement is not met as evidenced by:
Based on interview and record review, the licensee did not meet the staff ratios as specified by regional center. This violation poses a potential health and safety risk to the clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Eva M Alvarez
LICENSING EVALUATOR NAME:Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:
DATE: 12/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/29/2022


LIC809 (FAS) - (06/04)
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