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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600083
Report Date: 09/15/2023
Date Signed: 09/15/2023 11:27:04 AM

Document Has Been Signed on 09/15/2023 11:27 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:CHOICES R US - CLEVELANDFACILITY NUMBER:
198600083
ADMINISTRATOR:GISLENE PETNGA-DJIKIFACILITY TYPE:
735
ADDRESS:225 E CLEVELAND AVETELEPHONE:
(562) 942-1419
CITY:MONTEBELLOSTATE: CAZIP CODE:
90640
CAPACITY: 4CENSUS: 2DATE:
09/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Administrator Gislene Petnga- DjikiTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit and was greeted by Staff Jaquelin Ordonez and explained the reason for the visit.
The purpose of the visit is to complete the required inspection.
Shortly thereafter Administrator Gislene Petnga- Djiki arrived.
LPA toured the facility along with Staff Jaquelin Ordonez today 09/15/2023 at 9:00 AM and the following was observed:
Facility contains 2 Client Bedrooms and 2 Client Bathrooms, dining room, living room, and TV room.
Annual Inspection includes the following Domains:
Infection Control, Physical Plant and Environment Safety, Operational Requirements, Staffing, Personnel Records- Staff Training, Client Rights- Information, Client records- Incident Reports, Food Service, Health related services, Incidental Medical Services, and Disaster Preparedness.
Interviews were conducted with 2 staff. 2 clients were at Day Program. 2 client files were reviewed and 7 staff files were reviewed. All staff were cleared and associated.
Medication was administered per physician's directions.
Signage for hand washing and proper sanitizing were posted. Staff have been trained in hand washing.
Licensee maintained an individual admission agreement for each client.
Fire Clearance has been maintained.
Facility had sufficient supply of 2 day perishable and 7 day non-perishables meeting regulations.
Each client has personal rights free from corporal or unusual punishment, infliction of pain, humiliation, ridicule, coercion, threats, mental abuse, or other actions of a punitive nature.
There is an adequate number of direct care staff to support each resident's physical, social, emotional safety and health care needs as identified in his/her current appraisal.
Facility has a sufficient supply of PPE.
First Aid for staff are current.
No deficiencies. Exit interview conducted.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Glenn Trueman
LICENSING EVALUATOR SIGNATURE: DATE: 09/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2023
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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