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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601716
Report Date: 12/16/2021
Date Signed: 12/16/2021 04:20:36 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/10/2021 and conducted by Evaluator Angelica Rea
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20211210152408
FACILITY NAME:CHOICES R US - MIGUELFACILITY NUMBER:
198601716
ADMINISTRATOR:CARDENAS, GILBERTFACILITY TYPE:
735
ADDRESS:3951 MIGUEL AVETELEPHONE:
(562) 801-3061
CITY:PICO RIVERASTATE: CAZIP CODE:
90660
CAPACITY:4CENSUS: 4DATE:
12/16/2021
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Gilbert Cardenas and Adeshola Obayo-AkinmadeTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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9
Passageways in facility not free of obstructions.
Facility does not have adequate staffing
Facility is malodorous.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Angelica Rea conducted a visit in response to the above allegations. On today's visit, LPA met with Staff, Isidro Serrano who assisted with today's visit. Administrator, Adeshola Obayo-Akinmade arrived at the facility a short time later.

Regarding the allegation that Passageways in the facility are not free of obstructions, LPA reviewed photos obtained from reporting party, and toured the facilty on today's visit. LPA did not observe that common passageways were obstructed on today's visit. LPA did not observe that common passageways were obstructed in photos obtained. Regarding the allegation that facility does not have adequate staffing, LPA observed that there was one staff present on today's visit, and another staff arrived during the visit. LPA reviewed Resident #1 - Resident #4 files. Administrator stated that one resident currently receives one to one supervision at night. LPA reviewed facility personnel report and staff schedule. LPA observed sufficient staffing. Regarding the allegation that the facility is malodorous, LPA toured the facility and did not observe that the facility is malodorous.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Angelica Rea
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/10/2021 and conducted by Evaluator Angelica Rea
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20211210152408

FACILITY NAME:CHOICES R US - MIGUELFACILITY NUMBER:
198601716
ADMINISTRATOR:CARDENAS, GILBERTFACILITY TYPE:
735
ADDRESS:3951 MIGUEL AVETELEPHONE:
(562) 801-3061
CITY:PICO RIVERASTATE: CAZIP CODE:
90660
CAPACITY:4CENSUS: 4DATE:
12/16/2021
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Isidro SerranoTIME COMPLETED:
04:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility does not have sufficient non-perishable food supply on hand
Facility is not in good repair.
Facility is dirty
INVESTIGATION FINDINGS:
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2
3
4
5
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7
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9
10
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12
13
Licensing Program Analyst (LPA) Angelica Rea conducted a visit in response to the above allegations. On today's visit, LPA met with Staff, Isidro Serrano who assisted with today's visit. Administrator, Adeshola Obayo-Akinmade arrived at the facility a short time later.

Regarding the allegation that the facility does not have sufficient non-perishable food supply on hand, the investigation consisted of review of photos obtained from reporting party, and review of food supply, and review of facility grocery receipts. LPA observed that facility had sufficient food on today's visit, however facility
did not have a sufficient amount of nonperishable food on 12/3/21.

Regarding the allegation that the facility is not in good repair, the investigation consisted of review of photos obtained from reporting party. LPA observed that photos obtained showed a broken light switch in the bathroom, and a broken wall heater in the hallway and a broken wall heater in the living room. LPA observed that the light switch, and both wall heater(s) had been repaired.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Angelica Rea
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20211210152408
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CHOICES R US - MIGUEL
FACILITY NUMBER: 198601716
VISIT DATE: 12/16/2021
NARRATIVE
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Regarding the allegation that the facility is dirty, the investigation consisted of review of photos obtained from reporting party. LPA observed that photos obtained showed resident(s) rooms were cluttered with clothing, and trash.

Based on document review and interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiencies are being cited according to Title 22, Division 6.

An exit interview was conducted with Administrator. A copy of the report and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Angelica Rea
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20211210152408
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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: 12/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/16/2021
Section Cited
CCR
85076(d)(1)
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Food Service.
Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises. This requirement was not met as evidenced by : LPA observed that on 12/3/21, the facility did not have a sufficient amount of non perishable food.
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Administrator will ensure that the facilty has a sufficient amount of non perishable food supply at all times. The correction has been made prior to today's visit.
Type B
12/16/2021
Section Cited
CCR
80087(a)
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2
3
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5
6
7
Buildings and Grounds
The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement was not met as evidenced by: LPA observed that on 12/3/21 the facilty had a broken light fixture in the bathroom, and 2 broken wall heaters.
1
2
3
4
5
6
7
Administrator will ensure that the facility is in good repair at all times. The correction(s) have been made prior to today's visit.
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Type B
12/09/2021
Section Cited
CCR
80087(a)
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7
Buildings and Grounds
The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement was not met as evidenced by: LPA observed that on 12/3/21, residents room(s) were cluttered with clothing and trash.
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Administrator will ensure that the facility is clean and in good repair at all times. The correction(s) have been made prior to today's visit.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Angelica Rea
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20211210152408
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CHOICES R US - MIGUEL
FACILITY NUMBER: 198601716
VISIT DATE: 12/16/2021
NARRATIVE
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Based on LPA's observations and interviews, investigation revealed: Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Angelica Rea
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5