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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601806
Report Date: 03/20/2024
Date Signed: 03/20/2024 11:33:16 AM

Document Has Been Signed on 03/20/2024 11:33 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 - DOROTHYFACILITY NUMBER:
198601806
ADMINISTRATOR:DANIEL GODFREYFACILITY TYPE:
735
ADDRESS:10008 DOROTHY AVETELEPHONE:
(562) 445-3009
CITY:SOUTH GATESTATE: CAZIP CODE:
90280
CAPACITY: 4CENSUS: 3DATE:
03/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:12 AM
MET WITH:Gil Martinez - AdministratorTIME COMPLETED:
11:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) Tena Herrera conducted the required unannounced annual inspection. LPA met with Administrator Gil Martinez and explained the reason for the visit. The facility is licensed to serve (4) Ambulatory Only, Developmentally Disabled Adults, ages 18 through 59. Facility currently has 3 Ambulatory clients serviced by South Central Los Angeles Regional Center.

The facility is a single-story home located in a residential area in South Gate, Ca. A tour of the facility includes: living room, dining area, kitchen, 3 client bedrooms (one shared room with private bath), 2 bathrooms, detached garage (with laundry), front yard and back yard.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:


Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting clients’ medications. Staff are cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and, however, the Infection Control Plan was not available for review during visit details will be documented on the 809-D.
Physical Plant & Environment Safety: LPA toured facility, clients’ bedrooms were checked and closet/drawer space to accommodate each client comfortably was available. The backyard is free of debris/hazards and the outdoor and passageways are free of obstruction. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available for clients. The hot water temperature was tested in the client bathrooms and was within the required range of 105-120 degrees F. Cleaning solutions, toxins, knives, and hazardous items were observed to be in an unlocked cabinet under the kitchen sink, details will be cited on 809-D. Smoke detectors and carbon monoxide detectors are operable and in compliance. There fire extinguisher was observed and is fully charged. LPA observed 2 window screens to be bent and not secure on the window frame (details will be cited on the 809-D)
(Continued on 809-C)
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2024
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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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 - DOROTHY
FACILITY NUMBER: 198601806
VISIT DATE: 03/20/2024
NARRATIVE
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Operational Requirements: Staff have proper training to meet the needs of the clients in care. Facility has an activity area furnished for outdoor use. Last fire/earthquake drill was conducted on 12/1/23.
Staffing: There appears to be sufficient staffing at all times in the facility. With night staff that is trained and able to assist in care and supervision of the clients in the case of an emergency.
Personnel Records-Training: Staff files are maintained in a secure location. LPA reviewed 4 staff files during today’s visit, files reviewed contained the following: Criminal Background Clearance, First-Aid/CPR/AED/CPI and sufficient on-going training. Administrator Gil Martinez certificate that expired on 2/10/2024 but was able to show proof of classes and pending renewal (submitted 1/11/24).
Client Rights-Information: Facility provides telephone landline and internet for the clients. Client rights posters and reporting posters are displayed within the facility.
Client Records-Incident Reports: Client files are maintained in a secured locked cabinet and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan. LPA reviewed 3 client files with no issues.
Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.
Health Related Service: Staff designated to administer medication have the proper annual training on file. Medication is properly labeled and are centrally stored, however, upon arrival the cabinet that holds medication was observed to be unlocked while 1 client was in the facility (details will be cited on 809-D).
Incidental Medical & Dental: All training is documented in the facility personnel files. Staff performance is reviewed annually, and documentation is maintained in the personnel files.
Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites. Facility maintains documentation of the required emergency drills.
Emergency Intervention: Clients at this facility do not need the use of restraints or de-escalation techniques, however, staff are trained and maintain a CPI certificate if needed.

Per California Code of Regulations, Title 22, and California Health and Safety Code, deficiencies observed during todays visit will be documented on the 809D.

Exit interview was held and a copy of the report was given to Administrator Gil Martinez.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 03/20/2024 11:33 AM - It Cannot Be Edited


Created By: Tena Herrera On 03/20/2024 at 11:01 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 - DOROTHY
FACILITY NUMBER: 198601806

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as during tour LPA observed cleaning supplies under kitchen sink to be unlocked while a client was in the facility and had been in the kitchen just moments before LPA entered, LPA also observed unlocked detergent in unlocked laundry room in detatched garage, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/21/2024
Plan of Correction
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*staff quickly locked cabinet once observation was made, staff also locked laundry room once observation was made*
Administrator/Licensee to hold an in-service training on proper storage of disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients, a copy of the training material and training log with participant signatures to be emailed to LPA by 4/5/2024.
Type A
Section Cited
CCR
80075(k)(1)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as upon arrival and during tour LPA observed cabinet that holds medication and sharps to be closed but unlocked, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/21/2024
Plan of Correction
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*staff quickly locked cabinet once observation was made*
Administrator/Licensee to hold an in-service training on keeping medication safe and locked sot that it is not accessible to persons other than employees responsible for the supervision of the centrally stored medication, a copy of the training material and training log with participant signatures to be emailed to LPA by 4/5/2024.
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:Tena Herrera
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 03/20/2024 11:33 AM - It Cannot Be Edited


Created By: Tena Herrera On 03/20/2024 at 11:01 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 - DOROTHY
FACILITY NUMBER: 198601806

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85095.5(c)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 85022. 

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation/record review, the licensee did not comply with the section cited above as Infection Control Plan was not available for review during time of visit, administrator stated that it may have been misplaced, LPA tried researching previos 812's where it may be documented that there was a copy submitted to Licensing but there was nothing found within FAS to prove facility has an Infection Control Plan, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/05/2024
Plan of Correction
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Administrator/Licensee to develop an Infection Control Plan and includ it within the Plan of Operation, this plan must meet all required information as listed within the regulation listed above. A copy of the Infection Control Plan must be emailed to LPA by POC due date of 4/5/24. 
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as during tour LPA observed screens in shared bedroom and bedroom neighoring that one to be with bent window screens that are not secure to the window seal, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/05/2024
Plan of Correction
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Administrator/Licensee to repair screens and submit proof via photo to LPA by POC due date, via email.
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:Tena Herrera
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2024


LIC809 (FAS) - (06/04)
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