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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602392
Report Date: 05/30/2023
Date Signed: 05/30/2023 02:59:57 PM

Document Has Been Signed on 05/30/2023 02:59 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 - STOAKESFACILITY NUMBER:
198602392
ADMINISTRATOR:MARC SWEETFACILITY TYPE:
735
ADDRESS:9022 STOAKES AVETELEPHONE:
(562) 445-3009
CITY:DOWNEYSTATE: CAZIP CODE:
90240
CAPACITY: 4CENSUS: 4DATE:
05/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:21 AM
MET WITH:John Paul Adeleye- AdministratorTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced annual visit at the facility using the CARE Tool. LPA Mora met with Mike Johnson (Direct Support Professional) and explained the reason for the visit. Shortly after John Paul Adeleye (Administrator) showed up. The facility is licensed to serve 4 ambulatory only clients in the age range of 18 through 59. The facility is operating within the scope of the license.
A tour of the single-story facility included the living room, kitchen, dining area, 4 client bedrooms, 2 bathrooms, laundry area, front yard, backyard, and detached garage. LPA Mora conducted the tour with Mike Johnson and observed the following: sufficient food supplies for at least 2 days of perishables and 7 days of non-perishables were observed in the kitchen. Sharps were observed locked in the medication closet. Chemical and cleaning solutions are kept locked under the kitchen sink. The First Aid kit is kept locked in a kitchen cabinet and it is fully stocked with all required items including a current manual. Clean towels and extra clean linen were observed in each bedroom. Dining and living room have sufficient lighting and sitting area. Most medications are kept locked in the medication closet in the hallway. There are some medications kept in a kitchen cabinet and a metal box inside the refrigerator. This kitchen cabinet and metal box have a lock mechanism, but the locks are not working on both. Client files are kept in the medication closet and staff files are kept in the garage. All bedrooms have all required furniture, lighting, and bedding. Bedroom #1's window screen is damaged and has an opening. All bathrooms were observed with shower mats. The water temperature was tested in both bathrooms and measured at 113.1 degrees F and 112.1 degrees F, which is within the required 105-120 degrees F. Bathroom #1 is missing the toilet seat. A fire extinguisher was observed in the kitchen and it is fully charged. Smoke detectors were observed throughout the facility and in each room and were operable during the visit. There is a carbon monoxide in the laundry area and was operable during the visit. The front yard and backyard are clean. There is a shaded area with seating in the backyard. No bodies of water were observed at the facility. Passageways and exits are free of obstruction.

(Continued to LIC 809-C)
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE: DATE: 05/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/30/2023
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 - STOAKES
FACILITY NUMBER: 198602392
VISIT DATE: 05/30/2023
NARRATIVE
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LPA reviewed medication for all 4 clients and observed that medications are documented properly and given as prescribed. LPA reviewed files for all 4 clients and observed the following: Client 1, Client 2 and Client 4 have an incomplete physician report dated 04/07/2023. Only page 2 is incomplete. Client 3 went for a physical check up on 03/14/2023, however a physician report was not completed. Client 3 is missing the regional center admission agreement. Client 4 is missing both the facility and regional center admission agreement. LPA reviewed five staff files and observed no issues. LPA observed administrator certificate for John Paul Adeleye - 6051284735 with an expiration date of 08/05/2023. LPA interviewed 2 staff, 2 clients and attempted to interview the other 2 clients. LPA reviewed P&I funds for all 4 clients with 2 staff present. The facility has a surety bond valid from 08/19/2019 to 08/19/2023.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were deficiencies observed during the visit (Refer to LIC 809-D). Exit interview held and a copy of the report and appeal rights were provided.

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 05/30/2023 02:59 PM - It Cannot Be Edited


Created By: Luis Mora On 05/30/2023 at 02:08 PM
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 - STOAKES
FACILITY NUMBER: 198602392

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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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4
Based on observation, the licensee did not comply with the section cited above in 2 out of 3 locations which poses an immediate health, safety or personal rights risk to persons in care. The lock of a kitchen cabinet and metal box inside the refrigerator are not working. There are medications kept inside this cabinet and metal box.
POC Due Date: 05/31/2023
Plan of Correction
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Facility is to ensure that Title 22 Section 80075 regulations are met at all times. Additionally, facility will fix the locks on the kitchen cabinet and refrigerator metal medication box or move the medication to a locked location by 05/31/2023.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Wei Siew Ho
LICENSING EVALUATOR NAME:Luis Mora
LICENSING EVALUATOR SIGNATURE:
DATE: 05/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2023


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 05/30/2023 02:59 PM - It Cannot Be Edited


Created By: Luis Mora On 05/30/2023 at 02:08 PM
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 - STOAKES
FACILITY NUMBER: 198602392

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) 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 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 which poses/posed a potential health, safety or personal rights risk to persons in care. Kitchen cabinet's lock is not working and medication is kept inside this cabinet. The bathroom #1 toilet seat is missing. The bedroom #1 window screen is damaged and has an opening.
POC Due Date: 06/06/2023
Plan of Correction
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Facility is to ensure that Title 22 Section 80087 regulations are met at all times. Additionally, facility will fix all of the above by 06/06/2023.
Type B
Section Cited
CCR
80068(a)
Admission Agreements
(a) The licensee shall complete an individual written admission agreement with each client and the client's authorized representative, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 4 which poses/posed a potential health, safety or personal rights risk to persons in care. Client 3 is missing the regional center admission agreement. Client 4 is missing both the facility and regional center admission agreement.
POC Due Date: 06/13/2023
Plan of Correction
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Facility is to ensure that Title 22 Section 80068 regulations are met at all times. Additionally, facility will complete or obtain the admission agreements by 06/13/2023.
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:Wei Siew Ho
LICENSING EVALUATOR NAME:Luis Mora
LICENSING EVALUATOR SIGNATURE:
DATE: 05/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2023


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 05/30/2023 02:59 PM - It Cannot Be Edited


Created By: Luis Mora On 05/30/2023 at 02:23 PM
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 - STOAKES
FACILITY NUMBER: 198602392

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069(c)(4)
(c) The medical assessment shall include the following: (4) A determination of the client's ambulatory status, as defined by Section 80001(n)(2).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 3 out of 4 clients which poses/posed a potential health, safety or personal rights risk to persons in care. Client 1, Client 2 and Client 4 have an incomplete physician report dated 04/07/2023. Only page 2 is incomplete.
POC Due Date: 06/13/2023
Plan of Correction
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Facility is to ensure that Title 22 Section 80069 regulations are met at all times. Additionally, facility will have the physician report for Client 1, Client 2 and Client 4 completed by 06/13/2023.
Type B
Section Cited
CCR
80069(b)
(b) In ARFs , prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 4 clients which poses/posed a potential health, safety or personal rights risk to persons in care. Client 3 went for a physical check up on 03/14/2023, however a physician report was not completed.
POC Due Date: 06/13/2023
Plan of Correction
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Facility is to ensure that Title 22 Section 80069 regulations are met at all times. Additionally, facility will obtain a physician report for Client 3 by 06/13/2023.
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:Wei Siew Ho
LICENSING EVALUATOR NAME:Luis Mora
LICENSING EVALUATOR SIGNATURE:
DATE: 05/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2023


LIC809 (FAS) - (06/04)
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