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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600235
Report Date: 11/15/2024
Date Signed: 11/15/2024 02:38:11 PM

Document Has Been Signed on 11/15/2024 02:38 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
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: 3DATE:
11/15/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:22 PM
MET WITH:House Manager Deborah Lewis.TIME VISIT/
INSPECTION COMPLETED:
02:40 PM
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On 11/15/2024, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced case management visit at the facility listed above. LPA met with House Manager Deborah Lewis (Staff #2) and explained the purpose of the visit. The purpose of the visit is to confirm Staff#1 (S1) has been excluded from the facility. Community Care Licensing Division (CCLD) received a decision and order for S1 to be excluded from the facility. LPA conducted a tour of the facility and Staff #2 - Staff #4 was present.

No deficiencies were cited.

A copy of this report was discussed and a hard copy was provided to the House Manager Deborah Lewis.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2024
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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