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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601806
Report Date: 04/19/2022
Date Signed: 04/19/2022 01:23:52 PM

Document Has Been Signed on 04/19/2022 01:23 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:CHOICES R US - DOROTHYFACILITY NUMBER:
198601806
ADMINISTRATOR:DANIEL GODFREYFACILITY TYPE:
735
ADDRESS:10008 DOROTHY AVETELEPHONE:
(562) 445-3009
CITY:SOUTH GATESTATE: CAZIP CODE:
90280
CAPACITY: 4CENSUS: 3DATE:
04/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Daniel Godfrey, administratorTIME COMPLETED:
01:30 PM
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On 4/19/22 at 10:00 am Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced visit with a focus on infection control, food and medication review. LPA met with staff 1 (S1) and staff (S2) explained the reason for our visit. LPA observed that both S1 and S2 was not associated to the facility. LPA asked if Administrator Daniel Godfrey can join the inspection. Administrator Godfrey joined the visit at 10:57 AM.

Facility is licensed to serve 4 ambulatory adults only. The facility is in a residential area and is a one-story structure. The facility contains a living room, dining room, kitchen, 3 bedrooms and 2 bathrooms: bathroom#2 is a private bathroom for bedroom#3, a garage, which is not for client use, a front yard, a back yard with a shaded area for client use and a laundry room that is attached to the garage. The facility smoke/ carbon monoxide detectors tested in working condition.

LPA Baptiste and administrator Daniel Godfrey toured the physical plant and observed the following: required postings, working telephone, no bodies of water, adequate lighting and comfortable temperature throughout, hallways and doorways clean and free of debris and first aid kit fully stocked. Bedrooms #1, #2, and #3 was observed to have all the required furnishings. LPA toured the bathroom and observed the required signs with soaps and paper towels. Water temperature was tested in Bathroom#1 at 111.1 and Bathroom #2 at 110.3, which is within the required 105-120 degrees F. LPA toured the Kitchen and observed sharps inaccessible to clients, toxins storage observed, adequate food supply for 3 clients with 7 days non-perishables and 2 days perishable. Medications centrally stored and locked.

Report continued on 809c

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE: DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/19/2022
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CHOICES R US - DOROTHY
FACILITY NUMBER: 198601806
VISIT DATE: 04/19/2022
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LPA reviewed medications for all clients. last disaster drill conducted on 04/05/22, staff files was reviewed for S1 and S2 and LPA observed background clearance and fingerprints in the file. Administrator provided a copy of approval to associate all staff to central location. Document dated 4/28/2015. Since S1 and S2 was hired after receiving the waiver facility will obtain a guardian account and transfer S1 and S2. LPA assisted administrator with guardian account to get staff transferred


Exit interview was conducted with administrator and a copy of this report was issued
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2022
LIC809 (FAS) - (06/04)
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