<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601384
Report Date: 02/03/2023
Date Signed: 02/03/2023 01:00:02 PM

Document Has Been Signed on 02/03/2023 01:00 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 - BAIRNSDALEFACILITY NUMBER:
198601384
ADMINISTRATOR:GISLENE PETNGA DJIKIFACILITY TYPE:
735
ADDRESS:7322 BAIRNSDALE STTELEPHONE:
(562) 659-7082
CITY:DOWNEYSTATE: CAZIP CODE:
90240
CAPACITY: 4CENSUS: 4DATE:
02/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Gislene Petnga Djiki- AdministratorTIME COMPLETED:
01:10 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analysts (LPAs) Luis Mora and Erik Zaragoza conducted an unannounced annual visit using the Infection Control Evaluation Tool. LPA met with Gislene Petnga Djiki (administrator) and explained the reason for the visit. Physical Plant was toured, client files and medication records were reviewed, staff files were reviewed and food supply was inspected.

LPAs and Administrator toured the home and inspected 2 client bedrooms, 1 staff office, 2 client and 1 staff bathroom, kitchen, dining area, living room, laundry room, front yard, backyard, and attached garage. The front and backyard are well maintained and there are no pools or large bodies of water. There is a shaded seating area for the clients located in the backyard. Passageways and exits are free of obstruction. The water temperature was tested in all bathrooms and all measured at 105 degrees F which is not within the required 105 - 120 degrees. Client bedrooms have the required furniture such as bed frames, dressers, lamps and chairs. Bedrooms also have sufficient closet space. Client beds have the required linen and the linen is in good condition. There is a cabinet in the laundry room with extra clean linen and towels. Smoke detectors combined with carbon monoxides were observed in each room and throughout the facility, and are properly operating. There is one fire extinguisher located in the kitchen which is fully charged. Kitchen appliances are clean and were operating at the time of the visit. Sufficient supply of 2 days perishable & 7 days non-perishable foods were observed in the kitchen. Sharps are locked in a cabinet in the staff office and are inaccessible to clients. Cleaning supplies and toxins are locked in a cabinet in the laundry room and under the kitchen sink, and are inaccessible to clients. First Aid kit was fully stocked with current manual and it is kept locked in the medication cabinet in the staff office. Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing. A supply of 30 day Personal Protective Equipment (PPE) was observed in the staff office. Client medications and files are centrally stored in a locked cabinet in the staff office. Staff files are kept locked in a file cabinet in the staff office. All four of the client files and medications were reviewed and no deficiencies were found. Medications are documented properly and given as prescribed. (Continued to LIC 809C)
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE: DATE: 02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/03/2023
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 3
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 - BAIRNSDALE
FACILITY NUMBER: 198601384
VISIT DATE: 02/03/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Six staff files were reviewed and the following deficiencies were found: Staff 1 (S1) did not have a valid FIrst Aid/CPR certificate and Staff 2 (S2) did not have a valid Crisis Prevention Institute (CPI) certificate.

The licensee was granted a waiver under the Authority of Governor Newsom’s Executive Order N-11-22 issued on June 17, 2022, and the licensee agreed to submit the Infection Control Plan by 04/03/2023

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were deficiencies observed during the visit (Refer to LIC 809D). Exit interview held and a copy of the report and appeal rights were provided.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 02/03/2023 01:00 PM - It Cannot Be Edited


Created By: Luis Mora On 02/03/2023 at 12:26 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 - BAIRNSDALE

FACILITY NUMBER: 198601384

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 02/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(f)
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 6 staff which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/17/2023
Plan of Correction
1
2
3
4
Facility will submit valid First Aid/CPR certificates for S1 to CCLD by 02/17/2023
Type B
Section Cited
CCR
85065(f)
(f) The licensee shall ensure that all direct services to clients requiring specialized skills are performed by personnel who are licensed or certified to perform the service.


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 6 staff which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/17/2023
Plan of Correction
1
2
3
4
Facility will submit a Crisis Prevention Institute certificate for S2 to CCLD by 02/17/2023
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:Wei Siew Ho
LICENSING EVALUATOR NAME:Luis Mora
LICENSING EVALUATOR SIGNATURE:
DATE: 02/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2023


LIC809 (FAS) - (06/04)
Page: 3 of 3