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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600235
Report Date: 07/10/2024
Date Signed: 07/10/2024 11:30:29 AM

Document Has Been Signed on 07/10/2024 11:30 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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:ULTIMATE CARE 11FACILITY NUMBER:
198600235
ADMINISTRATOR/
DIRECTOR:		COLLETTE JOHNSON RAMIREZFACILITY TYPE:
735
ADDRESS:601 CENTER STREETTELEPHONE:
(310) 640-8686
CITY:EL SEGUNDOSTATE: CAZIP CODE:
90245
CAPACITY: 6CENSUS: 4DATE:
07/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:14 AM
MET WITH: House Manager Deborah LewisTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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On 07/10/2024 at 8:14 AM, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced Required – 1 Year Inspection to the above-named facility and met with House Manager Deborah Lewis. LPA explained the purpose of the visit and was accompanied by House Manager inside and outside the facility during this inspection. The facility is licensed to operate for (6) developmentally disabled adults ages 18 through 59 which (4) can be ambulatory and (2) non-ambulatory. Currently, the home has (2) ambulatory clients and (2) non-ambulatory clients.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: 4 bedrooms, 1 staff bedroom, 3 bathrooms, family room, living room/office, kitchen, dining room, patios with shaded areas, indoor and outdoor activity area, and laundry room in the detached garage.

Outside grounds were toured and no bodies of water were observed. Patio furniture under a shaded area was accessible to clients. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises.

4 out of 4 client’s bedrooms were checked. Mattresses were in good condition, adequate lighting, plenty of dresser and closet space observed. Walls and floors were clean and in good condition. Comforters, bed linen, bath towels and mattress protectors were adequately stocked. Bathroom toilets and water faucets worked properly. LPA Cloyd tested hot water temperature and it measured at 111.9 degrees Fahrenheit. This facility provides clients with hygiene products such as nonmedicated soap, toilet paper, toothbrush, toothpaste, and comb.

LPA observed supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days.



Continue to LIC809-C.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE: DATE: 07/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/10/2024
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 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: ULTIMATE CARE 11
FACILITY NUMBER: 198600235
VISIT DATE: 07/10/2024
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LPA observed that Medications were safe, locked and inaccessible. All medications observed were labeled and maintained in compliance with label instructions and State and Federal law. Documents are posted as mandated. Last Disaster drill was conducted on 05/17/24. First aid kit is fully stocked with manual. Smoke and carbon monoxide detectors were in compliance and operational.

Five (5) staff records were reviewed, 5 out of 5 staff records had current first aid certificates and had required criminal record clearances or criminal record exemptions.

Four (4) client records were reviewed and, 4 out of 4 client records had Admission Agreements, IPP/ISP, Annual Behavior Assessment & Behavior Intervention Plan and/or Needs & Services Plans. Two client medications were reviewed.

No deficiencies cited.

An exit interview was conducted, technical assistance provided, and a copy of this report was discussed and left with the House Manager Deborah Lewis.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2024
LIC809 (FAS) - (06/04)
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