198601587-10-13-2023-28-AS-EZAA-CWKT78-20231013142818

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601587
Report Date: 10/13/2023
Date Signed: 10/13/2023 02:28:46 PM

Document Has Been Signed on 10/13/2023 02:28 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 - ZAMORA		FACILITY NUMBER:	198601587
ADMINISTRATOR:	LASHON JOHNSON		FACILITY TYPE:	735
ADDRESS:	10524 E ZAMORA AVE		TELEPHONE:	(562) 445-3009
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90002
CAPACITY: 4		CENSUS: 3	DATE:	10/13/2023
TYPE OF VISIT:	Required - 1 Year	ANNOUNCED	TIME BEGAN:	12:35 PM
MET WITH:	Unique Johnson - DSP		TIME COMPLETED:	02:45 PM

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Licensing Program Analyst (LPA) Erik Zaragoza conducted an unannounced Required 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA explained the purpose of the visit to Unique Johnson a Direct Support Professional for the facility and explained the purpose of the visit. Administrator Lashon Johnson arrived shortly thereafter. There are two (2) ambulatory and one (1) non-ambulatory developmentally disabled clients who reside in the home. The facility is vendored through the South Central Los Angeles Regional Center.

The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Client Rights/Information, Client Records/Incident Reports, Food Service, Health Related Services, Incident Medical and Dental, Disaster Preparedness, and Emergency Intervention.

Infection Control:

· Infection control practices and Personal Protective Equipment (PPEs) were observed. LPA asked the administrator to email their infection control plan to LPA within 7 days.

Physical Plant/Environment Safety:

· The facility is a single-story home located in a residential neighborhood that is licensed for a capacity of four (4) developmentally disabled clients between the ages of 18-59, four (4) of which may be non-ambulatory. It consists of four (4) individual client bedrooms, a living room, dining room, a kitchen, two (2) shared client bathrooms of which R#1’s hot water temperature measured at 109.4 Degrees F, and a second shared restroom R#2 measured at 109.6 Degrees F, a front and back patio area, a laundry room, and a detached garage that stores the facility’s chemicals and cleaning supplies.

· The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2023

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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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 - ZAMORA	FACILITY NUMBER: 198601587
	VISIT DATE: 10/13/2023

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Fire alarm system is operational. The facility has one (1) fully charged fire extinguisher that is kept in the kitchen area of the facility. Cleaning supplies and toxic substances are inaccessible to clients in a locked storage area located within the detached garage of the facility.
· Water temperature readings measured between the required 105 - 120 degrees Fahrenheit.
Operational Requirements:
· The Program Design was reviewed.

· Fire clearance was approved by LA County Fire Department for four (4) developmentally disabled clients between the ages of 18 – 59. Four (4) of which may be non-ambulatory.

· Care and supervision to meet the clients’ needs was observed.
Staffing:

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

Personnel Records/Staff Training:

· Administrator’s certificate is active and effective through 5/24/2024.

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

· Physician orders were reviewed in client files.

Client Records/Incident Reports:

· Three (3) client files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, Appraisal/Needs and Services Plan, personal rights, medical consent, nutritional assessments, medication records, and P & I money were reviewed.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2023

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 - ZAMORA	FACILITY NUMBER: 198601587
	VISIT DATE: 10/13/2023

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Food Service:

· 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 clients require a restricted Health Care plan.

Health Related Services:

· Clients are assisted with self-administration of prescription and non-prescription medications.

· Three (3) centrally stored resident medication records were reviewed. Centrally stored medications are kept in a safe and locked place not accessible to clients in care. Medications are given according to Physician directions.

Incident 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 10/1/2023.

Emergency Intervention:

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

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held and a copy of the report along with appeal rights were provided.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2023

LIC809 (FAS) - (06/04)

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