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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600486
Report Date: 05/25/2024
Date Signed: 05/25/2024 04:26:37 PM

Document Has Been Signed on 05/25/2024 04:26 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:CHOICES R US - FAUSTFACILITY NUMBER:
198600486
ADMINISTRATOR/
DIRECTOR:		GILBERT CARDENASFACILITY TYPE:
735
ADDRESS:13019 FAUST AVETELEPHONE:
(562) 803-7969
CITY:DOWNEYSTATE: CAZIP CODE:
90242
CAPACITY: 4CENSUS: 3DATE:
05/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:53 PM
MET WITH: Lisa Mosley - CaregiverTIME VISIT/
INSPECTION COMPLETED:
04:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tena Herrera conducted the required unannounced annual inspection. LPA met with Caregivers Lisa Mosley and Katia Ocampo, and explained the reason for the visit. The facility is licensed to serve (4) Ambulatory Only Adults, ages 18 through 59, with an approved delayed egress device (facility currently does not use a delayed egress device). Facility currently has 3 Ambulatory clients serviced by South Central Los Angeles Regional Center.

The facility is a single-story home located in a residential area in Downey, Ca. A tour of the facility includes: living room, dining area, kitchen, 4 client bedrooms, 2 client bathrooms (1 private bath), attached garage (with laundry), front yard and back yard.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:


Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting clients’ medications. Staff are cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan maintained at the facility.
Physical Plant & Environment Safety: LPA toured facility, clients’ bedrooms were checked and closet/drawer space to accommodate each client comfortably was available. The backyard is free of debris/hazards and the outdoor and passageways are free of obstruction. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available for clients. The hot water temperature was tested in the kitchen and client bathroom and were within the required range of 105-120 degrees F. All storage areas for cleaning solutions, toxins, knives, and hazardous items are kept in a locked cabinet in the garage and are inaccessible to clients. Smoke detectors and carbon monoxide detectors are operable and in compliance. There fire extinguisher was observed and is fully charged. LPA observed window screen to Client #3's bedroom missing (details cited on 809-D).
Operational Requirements: Facility has an activity area furnished for outdoor use. Last fire/earthquake drill was conducted on 5/4/24.
(Continued on 809-C)
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE: DATE: 05/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/25/2024
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CHOICES R US - FAUST
FACILITY NUMBER: 198600486
VISIT DATE: 05/25/2024
NARRATIVE
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Staffing: There appears to be sufficient staffing at all times in the facility. With night staff that is trained and able to assist in care and supervision of the clients in the case of an emergency.
Personnel Records-Training: Staff files are maintained in a secure location. LPA was not able to access any staff records as files were in a locked cabinet and staff did not have access, Administrator did not attend inspection and they are the only one with the key to the cabinet (details will be cited on 809-D). Administrator Lan Ly maintains a valid certificate that expires on 9/29/24.
Client Rights-Information: Facility provides telephone landline and internet for the clients. Client rights posters and reporting posters are displayed within the facility.
Client Records-Incident Reports: Client files are maintained in a secured locked cabinet and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan. LPA reviewed 3 client files with no issues.
Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.
Health Related Service: Medication is properly labeled and are centrally stored in a locked cabinet and are in their original containers. However, during visit LPA observed Client #3's medication from evening 5/24/24 and morning medication from 5/25/25 to be in packaging, Medication Administration Record (MAR) was documented with "HV" (home visit) and both doses were missed. (details will be cited on 809-D)
Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites. Facility maintains documentation of the required emergency drills.
Emergency Intervention: Clients at this facility do not need the use of restraints or de-escalation techniques.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during todays visit will be documented on the LIC809-D.

Exit interview was held and a copy of the report with appeal rights and LIC9098 was emailed to Administrator Lan Ly, Caregiver Lisa Mosley, and Licensee Gilbert Cardenas .

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 05/25/2024 04:26 PM - It Cannot Be Edited


Created By: Tena Herrera On 05/25/2024 at 03:21 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 - FAUST
FACILITY NUMBER: 198600486

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type A
Section Cited
CCR
80075(b)(5)(B)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (B) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and converstation held with staff, the licensee did not comply with the section cited above as during medication review LPA obsereved medication for Client #3 from 5/24/24 PM medication and 5/25/24 AM medication to sitll be in medication box, when LPA asked staff what happened staff stated that Client is on a home visit was not sure why the medication was still at facility, this poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/26/2024
Plan of Correction
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Licensee/Administrator to contact primary physician and inform them that Client #3 missed PM medication from 5/24/25 and AM medications from 5/25/24 and ask for directive. Licensee/Administrator to email LPA by 5/26/24 with out come. Also, Licensee/Administrator shall schedule an all staff medication (for staff that administer medication) training to avoid these errors in the future, Medication training materials and training log to be emailed to LPA by 6/7/2024.
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:Tena Herrera
LICENSING EVALUATOR SIGNATURE:
DATE: 05/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/25/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 05/25/2024 04:26 PM - It Cannot Be Edited


Created By: Tena Herrera On 05/25/2024 at 03:21 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 - FAUST
FACILITY NUMBER: 198600486

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as during tour LPA observed the screen to client #3's bedroom that faces backyard to be missing, this poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/07/2024
Plan of Correction
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This POC was corrected today during visit as Staff Lisa Mosely found the window screen in the bushes and properly/securly placed it on the window.
Type B
Section Cited
CCR
80066(e)
80066 Personnel Records (e) All personnel records shall be maintained at the facility site and shall be available to the licensing agency for review.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and conversations with staff, the licensee did not comply with the section cited above as non of the staff files were not available for review during todays visit as the cabinet was locked and staff did not have key to open the cabinet, this poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/07/2024
Plan of Correction
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Licensee/Administrator to review regulation, and fill out LIC9098 correct deficiency number must be referenced, and this form will indicate that moving forward all files will be accessible to Licensing during a 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:David Sicairos
LICENSING EVALUATOR NAME:Tena Herrera
LICENSING EVALUATOR SIGNATURE:
DATE: 05/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/25/2024


LIC809 (FAS) - (06/04)
Page: 4 of 4