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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198600235
Report Date: 06/21/2022
Date Signed: 06/23/2022 10:16:22 AM

Substantiated


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:
06/21/2022
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Deborah Lewis, House ManagerTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Facility failed to follow proper protocol for COVID-19
INVESTIGATION FINDINGS:
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This amended LIC 9099 supersedes LIC9099A report dated 08/04/21. Licensing Program Analyst (LPA) Ana Soto initiated a subsequent complaint investigation for the allegation listed above.
Today’s complaint investigation was conducted with Deborah Lewis, the facility house manager.

LPA Soto conducted telephonic interviews with the Licensee Clinise Davis and Collete Ramirez, Administrator. LPA Soto also interviewed Deborah, staff #4, R#1 - R#3. Toured the kitchen and food pantry, living room, family room, room #1, and dining room. The LPA also requested copies of the following documents: Resident roster, Staff roster, Menu, Face sheets, weight log for R#1 -R#3, IPP, Physician's Report, and Doctor's visit's (if any).

Based on the LPA's investigation the investigation revealed the following: Allegation: Facility failed to follow proper protocol for COVID-19.Interviews conducted with Licensee and Administrator,

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2022
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 3
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: 06/21/2022
NARRATIVE
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 they stated that the Administrator reported the positive case for Covid 19 to CCLD until Monday 08/02/21, but the positive case for Covid 19 occurred on Saturday 07/31/21. They also stated that they did not report the positive case for Covid 19 to the Department of Public Health (DPH.) The facility was not following surveillance testing on a weekly basis. They were only testing the staff every 2 weeks and not surveillance testing the clients on a weekly basis. They failed to follow Covid 19 protocols. The facility should of reported the Covid 19 positive case on the day they found out. They should also reported to DPH at the same time they found out. The facility still must perform surveillance testing for staff and clients. The interviews conducted do concur with the above allegation.

Based on LPA’s observations and interviews which were conducted and records review, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed the following deficiency and issued a citation.

An exit interview was conducted with Deborah Lewis, Administrator, and a hard copy was provided along with Appeal Rights.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/04/2021
Section Cited
CCR
80072(a)(2)
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80072(a)2 - To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. This was not met as evidenced by: Based on the facility not following Covid 19 protocols, which poses a health and safety hazard for adults in care.
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The Administrator will review and train all staff on the protocols for covid 19. Will provide a copy of all those who attended, by email, fax, and/or mail, to LPA by Wednesday 08/11/21.
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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: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3