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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198600235
Report Date: 05/06/2022
Date Signed: 05/20/2022 07:50:23 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
08/03/2021 and conducted by Evaluator Ana Soto
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20210803131112
FACILITY NAME:ULTIMATE CARE 11FACILITY NUMBER:
198600235
ADMINISTRATOR:COLLETTE JOHNSON RAMIREZFACILITY TYPE:
735
ADDRESS:601 CENTER STREETTELEPHONE:
(310) 640-8686
CITY:EL SEGUNDOSTATE: CAZIP CODE:
90245
CAPACITY:6CENSUS: 4DATE:
05/06/2022
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Deborah Lewis, House ManagerTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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9
Staff member abuses residents
Staff failed to provide adequate food service
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ana Soto conducted a subsequent complaint investigation to deliver findings and decisions for the allegations listed above. Today’s complaint investigation was conducted with Deborah Lewis, the facility house manager

The investigation consisted of following: Interviews and Record reviews. LPA interviewed via telephone Licensee Clinise Davis and Collete Ramirez, Administrator. LPA Soto also interviewed Deborah, staff #4, R#1 - R#3. LPA Soto interviewed received the following documents on 08/04/21: Resident Roster, Staff Schedule, Face sheet, Menu, living room, family room, room #1, and dining room. Weight log for R#1 -R#3, IPP, Physician's Report, and Doctor's visit's (if any.)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2022
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 2
Control Number 11-AS-20210803131112
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: ULTIMATE CARE 11
FACILITY NUMBER: 198600235
VISIT DATE: 05/06/2022
NARRATIVE
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Based on the LPA's investigation, the investigation revealed the following.

For Allegation 1 – Staff member abuses residents. Interviews with Licensee, administrator, house manager, and S#4, they all deny any type of abuse to any residents. None of the staff as ever hit or yelled or abused clients any way. Interviews with R#1 - R#3, R#1 just rocked back and forth. That no one hits R#1, R#2 & R#3 are non-verbal, they could not communicate with LPA. LPA observed residents they did not have any visibly bruises on their persons. The interviews and observations did not concur with the above allegation.

Allegation 2 - Staff failed to provide adequate food service. Interviews with Licensee, administrator, house manager, and S#4, they all agreed that they give nutritional food at the facility. The meals they serve are well balanced meals. They serve fresh vegetables, protein, and fresh fruits. Interviews with R#1 - R#3, R#1 just rocked back and forth. They give R#1 good food. R#2 & R#3 are non-verbal, they could not communicate with LPA. LPA reviewed the menu and it does have well balanced meals and variety of different meals to be served. LPA also inspected the facility refrigerator and pantry. The refrigerator had plenty of meats, fresh vegetables and fresh fruits. Pantry was full of can foods and dried foods. The interviews and records reviewed did not concur with the above allegation.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated

An exit interview was conducted with Deborah Lewis, House Manager, and a copy of report was provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2