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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701142
Report Date: 03/02/2022
Date Signed: 03/02/2022 03:31:47 PM

Document Has Been Signed on 03/02/2022 03:31 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, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:CHOICE MANNER I, INC.FACILITY NUMBER:
342701142
ADMINISTRATOR:DAVIS, EVELYN LYNNFACILITY TYPE:
735
ADDRESS:1609 REMINGTON WAYTELEPHONE:
(209) 334-0570
CITY:LODISTATE: CAZIP CODE:
95242
CAPACITY: 6CENSUS: DATE:
03/02/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Facility Type: ARF
Application Type: CHOW
Capacity: 6
COMP II Participants: Davis, Evelyn Lynn, Administrator, Williams, Kelcey, Board Member,Walton, Gregory, Board Member, Hubbard, Kenneth, Board Member
Interview Method: Telephone interview
TIME COMPLETED:
03:31 PM
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On 03/02/2022 applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed the understanding of the California Code Title 22 Regulations. Signed LIC 809 with copy of photo ID have been obtained.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General provisions
6. Emergency Preparedness
7. Complaints & Reporting
Pre-licensing readiness
SUPERVISORS NAME: Darla Neeley
LICENSING EVALUATOR NAME: Katie Keith
LICENSING EVALUATOR SIGNATURE: DATE: 03/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/02/2022
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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