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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600241
Report Date: 06/27/2024
Date Signed: 06/27/2024 02:13:16 PM

Document Has Been Signed on 06/27/2024 02:13 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:CHOICES R US - SPRYFACILITY NUMBER:
198600241
ADMINISTRATOR/
DIRECTOR:		BRADFORD, SHAJUANAFACILITY TYPE:
735
ADDRESS:9614 SPRY STTELEPHONE:
(562) 302-0348
CITY:DOWNEYSTATE: CAZIP CODE:
90242
CAPACITY: 6CENSUS: 6DATE:
06/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:11 AM
MET WITH:Shajuana Bradford, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:25 PM
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Licensing Program Analyst (LPA) Daniel Konishi conducted an unannounced Annual Required Visit on 06/27/2024. LPA was met by Staff #1 (S1) and explained the purpose of the visit. S1 assisted in tour of facility. Administrator Shajuana Bradford arrived shortly after to the facility and was explained the purpose of the visit. There are six (6) level 4 developmentally disabled clients in the home. The facility is licensed for clients 18-59 years old. The facility has a fire clearance approved for six (6) ambulatory. All clients receive services from South Central Los Angeles Regional Center. LPA requested and obtained a copy of Personnel Report, and Resident Roster.

Infection Control:

· Infection control practices and Personal Protective Equipment (PPEs) were observed. LPA observed that the facility had a completed infection control plan.


Physical Plant/Environment Safety:

· LPA conducted a tour of the facility with S1 and observed the following: The facility is a single-story house located in a residential area and consists of three (3) client bedrooms, two (2) bathrooms, kitchen, dining room, den/TV room, living room, front yard, backyard, and shed.


· All passageways, walkways, driveway, steps and patio are free from obstructions. The front, back and side areas of the house are free of hazards.
· Linen Closet: Contained plenty linens, towels, and hygiene products.

· Fire extinguisher was observed on hallway last reviewed 05/29/2024.


· Smoke/carbon monoxide detectors are tested and in working condition.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2024
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 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CHOICES R US - SPRY
FACILITY NUMBER: 198600241
VISIT DATE: 06/27/2024
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· Cleaning supplies are kept locked under kitchen sink away from food supplies.
· Shared client bathrooms were observed to be clean and contained soap and paper towels. Signs promoting hand washing were observed. Water temperature in this bathroom#1 was measured at 112.2 degrees F and Bathroom #2 was measured at 112.8 degrees F which is in the required 105 – 120 degrees F per Title 22 Regulations.
· The fireplace located in the Den/TV room did not have a cover and is accessible to clients in care.

Operational Requirements:

· The facility is licensed to serve (6) six ambulatory developmentally disabled adults ages 18 thru 59 years old.
· Liability Insurance is confirmed and currently on file.
· Surety bond is confirmed and currently on file.

Staffing:
· A total of seven (7) full-time staff members provide care and supervision to the clients.

Personnel Records / Staff Training:

· Administrator’s certificate expires on 09/04/2025.


· Five (5) staff files were reviewed for criminal background clearance and training.
· Personnel records have health/Tuberculosis (TB) screenings, certifications, and 1st Aid/CPR training.

Client Rights/Information:



· Physician orders were reviewed in client files.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CHOICES R US - SPRY
FACILITY NUMBER: 198600241
VISIT DATE: 06/27/2024
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Client Records/Incident Reports:

· Six (6) client files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, Appraisal/Needs and Services Plan, Individual Program Plan, personal rights, medication records, and Personal and Incidental (P & I) money were reviewed.

Food Services:


· The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary.
· No restricted Health Care plan required for the clients in the facility.

Health Related Services:
· Clients are assisted with self-administration of prescription and non-prescription medications.

· Six (6) centrally stored resident medication records were reviewed.


· LPA observed cabinet located in hallway to be locked and inaccessible to residents. LPA reviewed six (6)
out of six (6) client medications and Medication Administration Record (MAR).

Incidental Medical and Dental:

· All clients have a Needs and Services Plan, and COVID-19 vaccination cards on file.

· Staff training was on file.

Disaster Preparedness, and Emergency Intervention:



· A posted Emergency Disaster Plan LIC 610D containing emergency evacuation information was observed.

· An emergency drill was last documented on 05/01/2024.


SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 06/27/2024 02:13 PM - It Cannot Be Edited


Created By: Daniel Konishi On 06/27/2024 at 01:47 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: 06/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(c)
Fixtures, Furniture, Equipment, and Supplies
(c) Fireplaces and open-faced heaters shall be inaccessible to clients to ensure protection of the clients' safety.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, fireplace located in the Den/TV room did not have a cover and is accessible to clients in care which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/04/2024
Plan of Correction
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Administrator ensure fireplace is inaccessible to clients. Administrator to secure the fireplace and sbmit a picture of the secured fireplace to the LPA by the POC due date.
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:David Sicairos
LICENSING EVALUATOR NAME:Daniel Konishi
LICENSING EVALUATOR SIGNATURE:
DATE: 06/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2024


LIC809 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CHOICES R US - SPRY
FACILITY NUMBER: 198600241
VISIT DATE: 06/27/2024
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Emergency Intervention:

· No manual restraints or seclusion are used with clients in care.

Deficiencies were noted on LIC809-D per Title 22 Regulations. Interview was conducted and copy of the report and Appeal Rights were provided to the Administrator.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2024
LIC809 (FAS) - (06/04)
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