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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600235
Report Date: 06/21/2022
Date Signed: 06/24/2022 03:39:06 PM

Document Has Been Signed on 06/24/2022 03:39 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:
06/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Deborah Lewis, House ManagerTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Ana Soto conducted an unannounced Annual inspection visit and infection control inspection to the above facility. LPA met with Deborah Lewis, House Manager and the purpose of today’s visit was explained.

There are currently (4) four Westside Regional Center consumers in placement. All (4) clients are ambulatory. The facility is a single-story structure located in a residential neighborhood. It consists of the following: 5 bedrooms, 3 bathrooms, family room, living room/office, kitchen, dining room, shaded area, indoor and outdoor activity area, laundry room in the attached garage.

LPA and House Manager toured the entire facility inside and out. Documents are posted as mandated by the DPH and CCLD. Bedrooms 1 - 4 are occupied by clients and contain the mandated furniture. Bedroom 5 is a staff bedroom. The (3) bathrooms are clean and operational. Smoke detectors and carbon monoxide detector are in compliance and operational. No firearms are stored at facility and no bodies of water present. Medications are stored, locked, and inaccessible to clients. 1 staff file is current, 1 resident file is current along with medications. The water temperature is at 115.6 degrees. A comfortable temperature is maintained in the facility. Ample supply of perishable and nonperishable food, linens and personal hygiene supplies are adequate, hazardous toxins and/or items are inaccessible to clients, 2 fire extinguishers are fully charged. First Aid kit complete and with manual. Exit, walkways and/or passageways, front and back yard are free of debris and/or hazards. The facility is in good repair. During the visit, LPA observed the facility infection control practices.

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.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
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LPA observed a sanitizing station at the facility entry, sanitizer/soap in the staff bathroom and additional sanitation supplies in the garage. LPA observed staff and clients wearing masks, an isolation room and required postings throughout the facility. The administrator advised LPA that sanitizer is administered to client with the supervision of staff, but sanitizers are not kept in their rooms for safety reasons. The facility has an approved and posted Mitigation plan. Visitors are logged and checked. The client’s temperatures are checked and logged 2x a day.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe any deficiencies, therefore no citations were issued at this time.

An exit interview conducted with Deborah Lewis, House Manager and copy of report provided

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
LIC809 (FAS) - (06/04)
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