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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198203215
Report Date: 04/05/2022
Date Signed: 04/05/2022 02:06:37 PM

Document Has Been Signed on 04/05/2022 02:06 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 CAREFACILITY NUMBER:
198203215
ADMINISTRATOR:COLLETTE JOHNSON RAMRIEZFACILITY TYPE:
735
ADDRESS:11709 SIMMS AVENUETELEPHONE:
(310) 644-1235
CITY:INGLEWOODSTATE: CAZIP CODE:
90303
CAPACITY: 6CENSUS: 4DATE:
04/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:53 PM
MET WITH:Uila Sekona and Clinese TIME COMPLETED:
02:20 PM
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On 4/5/22, Licensing Program Analyst (LPA) Stephanie Cifuentes conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA was met by staff and explained the purpose of today’s visit is the annual inspection visit concentrating on Infection Control Measure and was allowed entry into the facility. The facility is an ARF licensed for six (6) ambulatory client.

The facility is a one story home located in a residential neighborhood. It consists of the following: 4 client bedrooms and 3 bathrooms, living room, T.V/ game room, kitchen, dining room, unattached garage, washer and dryer, outdoor shaded area

LPA and House Manager Uila Sekona toured the physical plant. There were no bodies of water or obstructions on the premises. Beds and bedding supplies were in good condition, adequate lighting provided, storage for client personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational.

LPA observed the facility to be sanitary and appropriately furnished at the time of visit. The kitchen was inspected and there is a 2-day supply of perishable and a 7-day supply of non-perishable food available, maintained properly. One fully charged fire extinguishers was found in dining room.

During the visit, LPA observed the facility infection control practices. LPA observed screening protocol for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff were wearing face coverings, a 30-day supply of Personal Protective Equipment (PPE) is available and sign in and out logs for visitors and staff are present in the facility.

Advisories are on attached 9102-AN – LPA was informed by Licensee that fit testing was complete and viewed a copy of the invoice for the staff, so advisory is cleared.

An exit interview was conducted, and a copy of this report was provided to Uila Sekona, Administrator.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Stephanie Cifuentes
LICENSING EVALUATOR SIGNATURE: DATE: 04/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/05/2022
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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