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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600235
Report Date: 08/26/2021
Date Signed: 08/27/2021 02:47:33 PM

Document Has Been Signed on 08/27/2021 02:47 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
MONTEREY PARK, CA 91754
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:
08/26/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Deborah Lewis, House ManagerTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Ana Soto (LPA) conducted an unannounced case management visit for deficiencies. LPA Soto conducted today's visit with Deborah Lewis, the facility House Manager.

The facility failed to report that resident's and staff were Covid - 19 positive. The Administrator Ramirez was not aware of the daily running of the facility. The facility was issued a Health Order by DPH, facility did not post it as instructed and did not follow the order's guidelines. The facility also failed to follow the facility mitigation plan. .LPA Soto issued citations to the above facility.

Due to technical difficulties with printer, report and appeals right provided via email.

An exit interview conducted with Deborah Lewis, House manager, a report and Appeals Right were provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE: DATE: 08/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2021
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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Document Has Been Signed on 08/27/2021 02:47 PM - It Cannot Be Edited


Created By: Ana Soto On 08/26/2021 at 02:27 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 11
FACILITY NUMBER: 198600235

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/26/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied: Appeal Not Submitted Timely
Type B
08/26/2021
Section Cited
CCR
80061(a)

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80061(a) Each licensee or applicant shall furnish to the licensing agency reports as required by the Department, including, but not limited to, those specified in this section.
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Administrator will write a plan on how they will make sure they report everything that is reportable that happens in the facility by email, fax, and mail by POC due date 09/03/21.
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This was not met by evideced by: Based on observation and interviews facility failed to report an Epidecmic outbreak (Covid-19)
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Request Denied: Appeal Not Submitted Timely
Type B
08/26/2021
Section Cited
CCR80064(a)1-7

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80064(a) 1-7 Administrator - Qualifications and Duties. This was not met as evidenced by: based on obeservation and interviews failed to report, not follow Health Order or mitigation plan or know the daily runnings of the facility.
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Administrator will review the Administrator - Qualifications and Duties, and send LPA Soto written proof that Administrator reviewed manual. by email, fax, and mail by POC due date 09/03/21.
Request Denied: Appeal Not Submitted Timely
Type B
08/26/2021
Section Cited
CCR
80061(b)(1)(H)

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80061(b)(1)(H) Epidemic Outbreaks
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Administrator will conduct a training fpr all staff make sure they follow their mitigation plan by email, fax, and mail by POC due date 09/03/21.
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:Janae Hammond
LICENSING EVALUATOR NAME:Ana Soto
LICENSING EVALUATOR SIGNATURE:
DATE: 08/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/27/2021 02:47 PM - It Cannot Be Edited


Created By: Ana Soto On 08/26/2021 at 03:24 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 11
FACILITY NUMBER: 198600235

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/26/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied: Appeal Not Submitted Timely
Type B
08/26/2021
Section Cited
CCR
80072a2

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2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. This was not met as evident by Based on observations and interviews the faciity failed to post DPH Health order and abide by guidelines
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Administrator to train staff on the health order by POC due and provided LPA proof of all staff attending training by 09/03/2021.

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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:Janae Hammond
LICENSING EVALUATOR NAME:Ana Soto
LICENSING EVALUATOR SIGNATURE:
DATE: 08/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2021


LIC809 (FAS) - (06/04)
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