198601716-3-22-2024-28-AS-EZAA-D3LPF8-20240322111618

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601716
Report Date: 03/22/2024
Date Signed: 03/22/2024 11:17:54 AM

Document Has Been Signed on 03/22/2024 11:17 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	CHOICES R US - MIGUEL		FACILITY NUMBER:	198601716
ADMINISTRATOR:	CARDENAS, GILBERT		FACILITY TYPE:	735
ADDRESS:	3951 MIGUEL AVE		TELEPHONE:	(562) 801-3061
CITY:	PICO RIVERA	STATE: CA	ZIP CODE:	90660
CAPACITY: 4		CENSUS: 4	DATE:	03/22/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:27 AM
MET WITH:	Ysidro Castro - Caregiver		TIME COMPLETED:	11:31 AM

NARRATIVE

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Licensing Program Analysts (LPAs) 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 Isidro Sandoval, Direct Support Staff (DSP) of the facility, and was granted entrance. There are four (4) ambulatory clients that reside in the home.

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 observed that the facility had a completed infection control plan.

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) clients over the age of 18. It consists of three (3) client bedrooms, a kitchen, a dining room, living room, a client bathroom that had a hot water temperature reading measured at 105.4 Degrees F, a shaded outdoor patio area in the backyard which houses the washer and dryer machines, and a detached garage that acts as a storage for the facility. Knives are kept locked in a closet in the main hallway of the facility, along with the chemicals and cleaning supplies.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2024

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 03/22/2024 11:17 AM - It Cannot Be Edited

Created By: Erik Zaragoza On 03/22/2024 at 10:57 AM

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 - MIGUEL	FACILITY NUMBER: 198601716
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80070(a)

Client Records

(a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client. 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 4 clients, as the Medication Administration Records (MARs) for 1 out of 4 clients was not signatured up to the current date, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/05/2024
	Plan of Correction
1 2 3 4	Administrator is to ensure that the MARs is signed for all clients every time medications are distributed to clients. Administrator is to hold an in-service training and email the list of attendees and training materials to the Licensing Program Analyst (LPA) by the POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Erik Zaragoza

LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2024

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 - MIGUEL	FACILITY NUMBER: 198601716
	VISIT DATE: 03/22/2024

NARRATIVE

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· 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. Fire alarm system is operational. The facility has one (1) fully charged fire extinguishers that are kept in the facility. Cleaning supplies and toxic substances are kept locked and inaccessible to clients.
· 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) ambulatory clients between the ages of 18 – 59.

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

· A total of ten (10) full-time staff members provide care and supervision to the clients.

Personnel Records/Staff Training:

· Administrator’s certificate expires on 6/6/2024.

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

· Physician orders were reviewed in client files.

Client Records/Incident Reports:

· Five (5) 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 Personal and Incidental (P & I) money were reviewed.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2024

LIC809 (FAS) - (06/04)

Page: 3 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 - MIGUEL	FACILITY NUMBER: 198601716
	VISIT DATE: 03/22/2024

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Food Service:

· The kitchen was inspected and the food preparation area, and storage areas were observed to be clean and sanitary. A seven (7) day supply of non-perishable food and two (2) day supply of perishable foods were observed in the kitchen.

· No restricted Health Care plan required for the clients in the facility.

Health Related Services:

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

· Five (5) centrally stored client 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. The Medication Administration Records (MARs) for one (1) out of four (4) clients was not signed since 3/13/2024.
Incidental 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:

· An Emergency Disaster Plan LIC610D is kept in the facility.

· The last documented disaster drill was documented on 2/9/2024.

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, the deficiency observed during the visit is documented on the LIC809D. Exit interview held and a copy of the report along with appeal rights were provided. Report will be emailed to the administrator as LPA has run out of printer paper.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2024

LIC809 (FAS) - (06/04)

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