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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198203215
Report Date: 03/14/2024
Date Signed: 03/15/2024 08:39:40 AM

Document Has Been Signed on 03/15/2024 08:39 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 CAREFACILITY NUMBER:
198203215
ADMINISTRATOR:COLLETTE JOHNSON RAMRIEZFACILITY TYPE:
735
ADDRESS:11709 SIMMS AVENUETELEPHONE:
(310) 644-1235
CITY:INGLEWOODSTATE: CAZIP CODE:
90303
CAPACITY: 6CENSUS: 4DATE:
03/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:56 PM
MET WITH:Uila SekonaTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced required 1- year visit with the primary focus on Infection Control measures and using the new CARE Inspection Tool. Upon arrival at the facility, LPA Bunker conducted a risk assessment. Based on the assessment, the facility is clear of COVID-19 infection. LPA Bunker was properly screened for COVID-19 symptoms and LPA temperature was checked. LPA Bunker met the House Manager Uila Sekona and explained the purpose of today's Annual Inspection. LPA verified that the facility has an approved mitigation plan report and Infection Control Plan. There are currently four (4), Westside Regional Center Adult Residential Care Facility (ARF) consumers in placement.

The facility is a single-story family home located in a residential neighborhood. House Manager Uila Sekona and LPA Bunker toured the facility which consisted of the following: Living room, dining room, family room/den, kitchen, 4 bedrooms, 3 bathrooms, laundry area, patio shaded area, indoor/outdoor activity areas, and a detached garage. The front and back yard landscape is in good condition at the time of the visit.

Due to time constraints, LPA Bunker will return at a later date.

There were no deficiencies cited.

Exit interview conducted.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE: DATE: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2024
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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