198601384-1-22-2025-28-AS-MCOA-DD6MFD-20250122083406

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601384
Report Date: 01/21/2025
Date Signed: 01/22/2025 08:35:11 AM

Document Has Been Signed on 01/22/2025 08:35 AM - 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 - BAIRNSDALE		FACILITY NUMBER:	198601384
ADMINISTRATOR/ DIRECTOR:	GISLENE PETNGA DJIKI		FACILITY TYPE:	735
ADDRESS:	7322 BAIRNSDALE ST		TELEPHONE:	(562) 659-7082
CITY:	DOWNEY	STATE: CA	ZIP CODE:	90240
CAPACITY: 4		CENSUS:	DATE:	01/21/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:25 PM
MET WITH:	Germaine Smart, Direct Support Staff		TIME VISIT/ INSPECTION COMPLETED:	05:30 PM

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Licensing Program Analyst, Mayra Cota, and Licensing Program Manager (LPM) Adeline Ho conducted an unannounced annual visit using the Care Inspection Evaluation Tool (CARE). LPAs met with Germaine Smart, Direct Support Staff and Assistant Administrator Marc Sweet arrived thereafter and assisted with the visit and the tour of the facility. The reason for the visit was explained. The physical plant was inspected along with client and staff records. and food supply. The facility is licensed to serve developmentally disabled clients between the ages of 18 to 59 and receive services from South Central Regional Center. All three (3) clients were present at the time of the visit.

The facility is a single home, and it is located within a residential neighborhood. LPA, LPM and Administrator toured the home and inspected the following: two (2) client bedrooms, one (1) office, three (3) bathrooms, living room, kitchen, dining area and laundry room. The outdoor environment which consists of a front and backyard was observed to be well maintained and there are no pools or large bodies of water. A shaded area located in the back patio is available and accessible for the clients. Passageways and exits are free of obstruction. The water temperature was tested and retested. It is within the required regulation of 105 - 120 degrees F. Client bedrooms have the required furniture such as bed frames, dressers, adequate lighting, and chairs. Bedrooms also have sufficient closet space. Client beds have the required linen, and the linen is in good condition. Smoke and carbon monoxide detectors were observed throughout the facility and were tested and operable during the visit. There is one fire extinguisher in the dining area which was observed to be charged. The kitchen was observed for the ability to prepare and serve food.

Cont. 809C

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Mayra Cota
LICENSING EVALUATOR SIGNATURE:	DATE: 01/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2025

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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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 - BAIRNSDALE	FACILITY NUMBER: 198601384
	VISIT DATE: 01/21/2025

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Appliances in the kitchen were observed to be functional and clean. Sharps were observed to be locked in the office and are inaccessible to clients. Cleaning supplies and toxins are locked in a closet in the office and are inaccessible to clients. First Aid was not fully stocked and contained expired anti-biotic ointment. Medications are centrally stored and locked in the office. Three (3) Staff and three (3) Client files were reviewed during today's visit. Staff working at facility have fingerprint clearances. Administrator on file left the position in October / November 2024. CCLD was not notified of the change

Deficiencies are being cited. See LIC 809D.

Exit interview was conducted with the Assistant Administrator, Marc Sweet. A copy of the report, appeal rights was issued.

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Mayra Cota
LICENSING EVALUATOR SIGNATURE:	DATE: 01/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/22/2025 08:35 AM - It Cannot Be Edited

Created By: Mayra Cota On 01/21/2025 at 04:52 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: 01/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85061(b)

85061(b) Reporting Requirements (b) The licensee shall notify the licensing agency, in writing, within 30 days of a change of administrator. This requirement is not met as evidenced by: Aministrator on file left the position in October / November 2024. CCLD was not notified of the change.
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above because Administrator on file left the position in October / November 2024. CCLD was not notified of the change which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/31/2025
	Plan of Correction
1 2 3 4	Administrator will submit required documents with current Administrator information to LPA within a week.

Type B

Section Cited

CCR

80075(g)(1)(H)

80075(g)(1)(H) Health Related Services (g) If the facility has no medical unit on the grounds, first aid supplies shall be maintained and be readily available in a central location in the facility. (1) The supplies shall include at least the following: (H) Antiseptic solution. This requirement is not met as evidenced by: First Aid was not fully stocked and contained expired anti-biotic ointment.
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above because First Aid was not fully stocked and contained expired anti-biotic ointment which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/24/2025
	Plan of Correction
1 2 3 4	Administrator will replace expired anti-biotic ointment and replenish First Aid kit accordingly. Administrator will purchase items within two days and send LPA purchase recepits and photo of fully replenished First Aid Kit.

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:

Mayra Cota

LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2025

LIC809 (FAS) - (06/04)

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