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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600241
Report Date: 10/19/2021
Date Signed: 10/19/2021 01:34:23 PM

Document Has Been Signed on 10/19/2021 01:34 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:CHOICES R US - SPRYFACILITY NUMBER:
198600241
ADMINISTRATOR:BRADFORD, SHAJUANAFACILITY TYPE:
735
ADDRESS:9614 SPRY STTELEPHONE:
(562) 302-0348
CITY:DOWNEYSTATE: CAZIP CODE:
90242
CAPACITY: 6CENSUS: 2DATE:
10/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Shajuana Bradford, administratorTIME COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Spencer conducted an unannounced annual inspection focusing on the Infection Control Domain. LPA Spencer was greeted by administrator Shajuana Bradford and discussed the purpose of today's visit. This single-story home contains three (3) client bedrooms, two (2) bathrooms, a living room, kitchen, dining area, den, and backyard.
The following was observed/inspected:
  • The facility had a universal entrance screening area including a thermometer and hand-sanitizer. COVID-19 signage was placed in several areas of the facility and temperature logs were maintained.
  • Facility did not maintain a 30-day supply of PPE to include masks, gowns, and face shields.
  • There was a sufficient supply of 2-day perishables and 7-day supply of non-perishable foods.
  • Cleaning solutions and sharps were locked and inaccessible.
  • One (1) out of four (4) stove burners was found to be in disrepair and did not light.
  • Each room contained required furniture including bed, dresser, night stand, lamp and chair.
  • Four (4) out of six (6) beds did not contain all of the required linen including mattress cover, fitted sheet, flat sheet, blanket, and comforter.
  • Bathrooms contained supplies including liquid soap, toilet paper, and paper towels (upon request).
  • Medications were locked, centrally stored, and given as prescribed. 30-day supply was maintained.
  • Staff wore face masks consistently throughout the shift and group activities were spaced to encourage physical distancing.
  • Smoke detectors/carbon monoxide detectors were present and operable.
  • A fire extinguisher was observed to be fully charged and last serviced July 2021.
  • Client files were inspected and emergency contact information and physician's reports were up-to-date.
  • All staff files were inspected and contained required health screenings, criminal record clearances, and training certificates.
  • An updated administrator certificate was not observed and expired on 9/4/21.
Pursuant to Title 22, deficiencies were cited on attached 809D. An exit interview was conducted and a copy of this report and Appeal Rights were provided to the administrator.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: LaJean Nicole Spencer
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2021
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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Document Has Been Signed on 10/19/2021 01:34 PM - It Cannot Be Edited


Created By: LaJean Nicole Spencer On 10/19/2021 at 12:30 PM
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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CHOICES R US - SPRY
FACILITY NUMBER: 198600241

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2021

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
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Based on observatio, the licensee did not comply with the section cited above in 1 out of 4 stove burners which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/22/2021
Plan of Correction
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Administrator stated that stove burner will be fixed and will send photo proof of repaired rear right side stove burner by POC due date.
Type B
Section Cited
CCR
85088(c)(4)
Fixtures, Furniture, Equipment, and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (4) Clean linen in good repair, including lightweight, warm blankets and bedspreads; top and bottom bed sheets; pillow cases; mattress pads; rubber or plastic sheeting, when necessary; and bath towels, hand towels and wash cloths.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above in 4 out of 6 bedswhich posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/19/2021
Plan of Correction
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Administrator purchased mattress covers and placed fitted and flat sheet on the client's bed to ensure that all beds had the required linens. The deficiency was cleared prior to the end of the visit.
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:Christine Yee
LICENSING EVALUATOR NAME:LaJean Nicole Spencer
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/19/2021 01:34 PM - It Cannot Be Edited


Created By: LaJean Nicole Spencer On 10/19/2021 at 12:42 PM
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 CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CHOICES R US - SPRY
FACILITY NUMBER: 198600241

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85064(b)
Administrator Qualifications and Duties
(b) All adult residential facilities shall have a qualified and currently certified administrator.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in due to an administrator certificate that expired on 9/4/21 which poses/posed a potential health, safety or personal rights risk to persons in care. The administrator stated that she is currently completing her required hours of training and will submit paperwork to receive updated certificate.
POC Due Date: 10/22/2021
Plan of Correction
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The administrator stated that she will send proof of mailed required documents to process administrator certificate by POC due date. Once administrator certificate is received, administrator will send copy to CCL.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Christine Yee
LICENSING EVALUATOR NAME:LaJean Nicole Spencer
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2021


LIC809 (FAS) - (06/04)
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