<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600235
Report Date: 06/14/2023
Date Signed: 06/14/2023 11:46:17 AM

Document Has Been Signed on 06/14/2023 11:46 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 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: 3DATE:
06/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:24 AM
MET WITH:Ivana Reyes-Director of Client ServicesTIME COMPLETED:
11:45 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 6/14/2023 Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Ivana Reyes/Director of Client Services and the purpose of today’s visit was explained. The facility is licensed to operate for (6) developmentally disabled or Mentally Ill adults ages 18 through 59 which (4) can be ambulatory and (2) non-ambulatory. Currently, the home has (3) ambulatory clients. The clients are from: Westside Regional Center. (0) clients have Restricted Health Care Conditions, and (0) are utilizing postural supports or protective devices.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: 4 bedrooms, 3 bathrooms, family room, living room/office, kitchen, dining room, patios with shaded areas, indoor and outdoor activity area, laundry room in the attached garage.

LPA Iniguez and Director toured the inside and outside of the facility (see D page for citation). All client rooms were checked. Mattresses and box springs were in good condition, adequate lighting was observed, plenty of dresser and closet space was observed. Bed linens, comforters and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulation. Toilets and water faucets worked properly. Shower was free of mold/mildew, there is adequate lighting, and sufficient toiletries accessible to clients. The water temperature properly measured between 105F°-120F° degrees (Kitchen 115.7F°, Bathroom #1 116.1°F., Bathroom #2 114.9F° and Bathroom #3 115.6F° ).

Evaluation Report continues LIC 809-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE: DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: ULTIMATE CARE 11
FACILITY NUMBER: 198600235
VISIT DATE: 06/14/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Carbon monoxide/Smoke detectors combo were observed and operational. Fire extinguishers were fully charged, toxins and knifes were locked and inaccessible to clients. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked.

LPA conducted a records review of (3) client records, (3) staff records (see D page for citation) and reviewed the facility disaster plan. The facility disaster plan was current and in compliance with Title 22 at the time of visit. LPA reviewed (3) Client Medication Administration Records (MAR) and did not observe any discrepancies at the time of visit.

Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8.

See D page(s) for Citations.

Exit interview conducted and a copy of the appeal rights were given to Ivana Reyes/Director of Client Services at the time of the visit.


SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3
Document Has Been Signed on 06/14/2023 11:46 AM - It Cannot Be Edited


Created By: Alfonso Iniguez On 06/14/2023 at 11:34 AM
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: 06/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation the licensee did not comply with the section cited above in maintaining the facility in good repair which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/05/2023
Plan of Correction
1
2
3
4
Licensee will ensure facility will be in good repair at all time. Window frame will be replace. A proof of correction will be sent to LPA via email before POC due date.
Type B
Section Cited
CCR
80066(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review the licensee did not comply with the section cited above in keeping staff TB test in file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/05/2023
Plan of Correction
1
2
3
4
Licensee will ensure S#1 TB test will be in file at all times. A proof of correction will be sent to LPA via email before POC due date.
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:Eva M Alvarez
LICENSING EVALUATOR NAME:Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3