198601384-12-15-2023-28-AS-THEA-CYJTA3-20231215133252

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601384
Report Date: 12/15/2023
Date Signed: 12/15/2023 01:33:41 PM

Document Has Been Signed on 12/15/2023 01:33 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 - BAIRNSDALE		FACILITY NUMBER:	198601384
ADMINISTRATOR:	GISLENE PETNGA DJIKI		FACILITY TYPE:	735
ADDRESS:	7322 BAIRNSDALE ST		TELEPHONE:	(562) 659-7082
CITY:	DOWNEY	STATE: CA	ZIP CODE:	90240
CAPACITY:	4	CENSUS: 4	DATE:	12/15/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:16 AM
MET WITH:	Gislene Pentega Djiki - Administrator		TIME COMPLETED:	01:32 PM

NARRATIVE

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Licensing Program Analyst (LPA) Tena Herrera conducted the required unannounced annual inspection. Upon arrival there were no Staff nor Clients at the facility as clients were away at day program, shortly after, LPA met with Gislene Pentega Djiki (Administrator) and explained the reason for the visit. The facility is licensed to serve 4 ambulatory clients ages 18-59. Facility currently has 4 ambulatory clients serviced by the 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 room, kitchen, laundry area, Staff office, 2 ½ bathrooms, 2 bedrooms, attached garage, front yard and back yard.

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 throughout the facility and measured below the required range 105-120 degrees F, client bathrooms water temperature measured between 66.0 – 85.6 degrees F (details will be found on the 809-D). All storage areas for cleaning solutions, toxins, knives, and hazardous items are kept in a locked 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. Last fire/disaster/earthquake drill was conducted on 10/1/23.
Operational Requirements: Staff have proper training to meet the needs of the clients in care. Facility has an activity area furnished for outdoor use.
(continued on 809-C)

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023

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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Document Has Been Signed on 12/15/2023 01:33 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80088(e)(1)

Fixtures, Furniture, Equipment, and Supplies

(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as during facility tour LPA observed water temperatures within each client restroom to measure between 66.0 - 85.6 degrees F, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/22/2023
	Plan of Correction
1 2 3 4	Administrator adjusted water temperature during visit Administrator to create a water temperature log for the next 5 days and test water temperature 3 times a day, morning, day and evening. This log shall begin morning of 12/16/23 and end evening of 12/20/23 and be emailed to LPA by 12/22/23 before end of day. Log shall state time water is tested, date, and temperature; all readings must be within the required range of 105-120 degrees F.

Type B

Section Cited

CCR

80069(c)(4)

80069 Client Medical Assessment (c) The medical assessment shall include the following: (4) A determination of the client's ambulatory status, as defined by Section 80001(n)(2). 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 as 1 out of 4 client files reviewed had a phyician report that stated client is non-ambulatory (after LPA contacting Regional Center it was determined that during visit conducted in 10/2023 client ambulatory status was "ambulatory", phyician report was dated in 2022 indicating non-ambulatory), which posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/22/2023
	Plan of Correction
1 2 3 4	Admninistrator to obtain an updated Physicians Report that shows clients current ambulatory status as "ambulatory", this Physicians report must be signed by doctor and a copy of entire report shall be sent via email to LPA by POC due date. (this is for client last name Ly)

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	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023

LIC809 (FAS) - (06/04)

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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: 12/15/2023

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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 locked in a secure location within the Staff Office. LPA reviewed 5 staff files during today’s visit with no issues observed. All files reviewed contained the following: criminal record clearance, current First Aid/CPR/AED/CPI and sufficient on-going training. Administrator Gislene Pentega Djiki certificate expired on 3/7/2023 but was able to furnish proof of pending renewal.
Client Rights-Information: The facility does not have any clients that require postural supports. Facility provides telephone landline for the clients.
Client Records-Incident Reports: Client files are maintained in a secure location within the Staff Office 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 4 client files today only 1 had a questionable form, all others had no issues. 1 clients physician report indicated that client is non-ambulatory, after contacting regional center it was determined that there was an error within the physician report and client is indeed ambulatory (citation details explained on the 809-D).
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: Staff designated to administer medication has the proper annual training on file. Medication is properly labeled and are centrally stored in a cabinet within staff office and are in their original containers. LPA reviewed 3 clients medications and there were no issues observed. (1 client does not currently take any medication)
Incidental Medical & Dental: All training is documented in the facility personnel files. Staff performance is reviewed annually and documentation is maintained in the personnel files.
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, with the last drill conducted on 10/1/2023.
Emergency Intervention: Clients at this facility have not needed the use of restraints or the use de-escalation techniques.
Per California Code of Regulations, Title 22, and California Health and Safety Code, deficiencies observed during today’s visit are documented on the 809-D.
Exit interview was held and a copy of the report was provided to Gislene Pentega Djiki.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023

LIC809 (FAS) - (06/04)

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