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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198203215
Report Date: 05/22/2024
Date Signed: 05/22/2024 05:52:12 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/17/2024 and conducted by Evaluator Regina Cloyd
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20240517123338
FACILITY NAME:ULTIMATE CAREFACILITY NUMBER:
198203215
ADMINISTRATOR:COLLETTE JOHNSON RAMRIEZFACILITY TYPE:
735
ADDRESS:11709 SIMMS AVENUETELEPHONE:
(310) 644-1235
CITY:INGLEWOODSTATE: CAZIP CODE:
90303
CAPACITY:6CENSUS: 4DATE:
05/22/2024
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:House Manager Uila Sekona TIME COMPLETED:
06:00 PM
ALLEGATION(S):
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Staff do not maintain adequate records for resident.
INVESTIGATION FINDINGS:
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On 05/22/2024 Licensing Program Analyst (LPA) Regina Cloyd conducted a complaint investigation at the above facility to address the following allegation(s). LPAs met with House Manager Uila Sekona and explained the purpose of the visit. The investigation consisted of the following: During today’s investigation, LPA reviewed (3) Client Records, Staff Schedule, and interviewed four (4) residents and four (4) staff members which includes the House Manager and (3) Direct Care Staff.

Continue to LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
Control Number 11-AS-20240517123338
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
FACILITY NUMBER: 198203215
VISIT DATE: 05/22/2024
NARRATIVE
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Allegation(s):
Staff do not maintain adequate records for resident.

The investigation revealed the following: Regarding the allegation "Staff do not maintain adequate records for resident,” it is being alleged that Resident #1 (R1) MD orders and special diet were not available for review, April MARs were not on site, blood sugar readings are recorded on a “Blood Pressure Log”, unnecessary items are listed on MAR, staff are merely checking off the days/times for medications being administered vs putting their initials, there are no staff signatures on MAR, and PRN medication (albuterol and diclofenac cream) does not indicate the reason as to why it was given for as should be noted on reverse side of MAR. Record review reveals that R1’s doctor’s visits on 03/25/24 and 04/30/24 (for a physical exam) was on file but it did not contain special diet information. Interview with the House Manager indicated that R1’s doctor does not like to complete the Physician’s Report (LIC 602). Record review reveals that May MAR, Blood Pressure Log with blood sugar readings as of 05/01/24, and Blood Sugar Log as of 05/21/2024 was on site. Interview with the House Manager indicated that a report is completed and previous MARs are sent to the main office and as of 05/22/24 3:20 PM, the office was closed. Interview with the House Manager also indicated that the facility ran out of Blood Sugar Logs and used the Blood Pressure Log as a temporary replacement. Record review reveals that MAR is checked off and staffs’ initials are listed on the back of the MAR; however, the charting instructions on the document is not followed. In addition, the MAR does not include the reason as to why the PRN medications were given. Regarding the allegation “Staff do not maintain adequate records for resident,” based on record reviews, interview(s), and observation the preponderance of evidence has been met therefore the allegation is Substantiated.

Deficiencies were issued.

An exit interview was conducted and plans of correction developed. A copy of this report and appeals rights was reviewed and left with House Manager Uila Sekona.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Citations on this Visit Report are Under Appeal!

Control Number 11-AS-20240517123338
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
FACILITY NUMBER: 198203215
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type B
06/05/2024
Section Cited
CCR
80070(a)
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Client Records (a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client. This requirement was not met as evidenced by:

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The Administrator will provide complete records for R1, including but not limited to, medical assessment that includes special diet restriction. Administrator will provide a blood sugar log template and evidence of MAR charting training according to instructions on MAR and documenting PRN usuage.
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During record review, LPA Cloyd did not observe complete records for R1.
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Administrator to email R1 documents and training evidence to regina.cloyd@dss.ca.gov by the POC due date.
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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.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/17/2024 and conducted by Evaluator Regina Cloyd
COMPLAINT CONTROL NUMBER: 11-AS-20240517123338

FACILITY NAME:ULTIMATE CAREFACILITY NUMBER:
198203215
ADMINISTRATOR:COLLETTE JOHNSON RAMRIEZFACILITY TYPE:
735
ADDRESS:11709 SIMMS AVENUETELEPHONE:
(310) 644-1235
CITY:INGLEWOODSTATE: CAZIP CODE:
90303
CAPACITY:6CENSUS: 4DATE:
05/22/2024
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:House Manager Uila Sekona TIME COMPLETED:
06:00 PM
ALLEGATION(S):
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Staff mismanaged resident's medications.
Staff are not administering medications as prescribed to resident.
INVESTIGATION FINDINGS:
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On 05/22/2024 Licensing Program Analyst (LPA) Regina Cloyd conducted a complaint investigation at the above facility to address the following allegation(s). LPAs met with House Manager Uila Sekona and explained the purpose of the visit. The investigation consisted of the following: During today’s investigation, LPA reviewed (3) Client Records, Staff Schedule, and interviewed four (4) residents and four (4) staff members which includes the House Manager and (3) Direct Care Staff.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 11-AS-20240517123338
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
FACILITY NUMBER: 198203215
VISIT DATE: 05/22/2024
NARRATIVE
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Allegation(s):
Staff mismanaged resident's medications.

The investigation revealed the following: Regarding the allegation "Staff mismanaged resident's medications,” it is being alleged that staff could not locate Seroquel and Prilosec on his MAR, although, they were checked off as given for the 8:00 am medication distribution. It is also being alleged that (R1’s) Albuterol Inhaler is listed “as needed for SOB”; however, it has been checked off as given every am at 8:00 am for this month and once at noon on 5/1/24. Another PRN, Diclofenac cream is also listed as given every day this month." Record review revealed that Quetiapine Seroquel was listed on the May MAR but not Prilosec. LPA did not observe Prilosec during medication review. Interview with the House Manager indicated that R1 uses Albuterol every morning because R1 smokes and uses diclofenac cream daily for knee pain. R1 denied using albuterol this month. Based on record review, interview, and observations, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated.

Allegation(s):
Staff are not administering medications as prescribed to resident.



The investigation revealed the following: Regarding the allegation "Staff are not administering medications as prescribed to resident,” it is being alleged that R1’s Glipizide 10 mg and Protonix qam is to be given 30 minutes before meals 2x daily. Staff advised that breakfast is served between 7- 7:30 am and dinner between 5-6 pm. However, medication is checked off at 8:00 am and 4:00 pm on MAR consistently. Client self-administers his own Humolog insulin 3x per day & Glargine insulin 2x per day. The latter is a different amount for pm (25 units/am & 22 units/pm). The different dosages of Glargine should be separated on the MAR—not listed as one. Record review revealed that medication is distributed at 8:00 AM and 4:00 PM. Interview with the House Manager indicated that R1 takes medication at 8:00 AM and 4:00 PM and eats meals thirty minutes afterwards. Two (2) out of 3 Direct Care Staff interviews indicated that medication is distributed at 8:00 AM and 4:00 PM. Interview with the House Manager indicated that dinner is served between 4:30 PM – 5:00 PM. LPA Cloyd observed clients eating around 4:48 PM. Record review revealed that Glargine insulin 25 units is distributed in the morning and 22 units distributed at bedtime is listed on the same row. Continue to LIC 809-C.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 11-AS-20240517123338
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
FACILITY NUMBER: 198203215
VISIT DATE: 05/22/2024
NARRATIVE
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LPA Cloyd observed that the (1) Glargine insulin pen is adjustable to distribute different unit amounts.
Interview with House Manager and (1) Direct Care Staff indicated that staff is aware of which dose is taken. Interview with R1 indicated that R1 manages own medication. Record review reveals that R1 has a restricted health care plan on file. Regarding the allegation “Staff are not administering medications as prescribed to resident,” based on record reviews, interviews, and observations, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated.

No deficiency was cited for this allegations.

An exit interview was conducted and a copy of this report was provided to the House Manager Uila Sekona.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6