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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701142
Report Date: 03/24/2022
Date Signed: 03/24/2022 04:43:48 PM

Document Has Been Signed on 03/24/2022 04:43 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:CHOICE MANNER I,INCFACILITY NUMBER:
342701142
ADMINISTRATOR:DAVIS, EVELYN LYNNFACILITY TYPE:
735
ADDRESS:1609 REMINGTON WAYTELEPHONE:
(209) 334-0570
CITY:LODISTATE: CAZIP CODE:
95242
CAPACITY: 6CENSUS: 6DATE:
03/24/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Elizabeth Davenport, AdministratorTIME COMPLETED:
11:35 AM
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On 03/24/2022 at 9:00 AM Licensing Program Analyst (LPA) T. White arrived unannounced to conducted a Pre-Licensing Inspection of the facility to ensure compliance with Title 22 regulations. LPA met with Administrator, Elizabeth Davenport who assisted LPA in today’s inspection. Fire clearance licensed for 6 ambulatory clients. The facility administrator’s certificate #6047709735 which expires on 04/03/2022.

LPA inspected the interior and the exterior of the facility including the common living spaces, client bedrooms bathrooms, and kitchen. LPA observed all hallways and passageways to be free of clutter or hazards. LPA observed kitchen was clean and in good repair. Facility has (7) seven day supply of non-perishables and two (2) perishable foods. Client bedrooms were checked and were observed to be adequately furnished. LPA observed adequate supply of linens. LPA tested water temperature in client's shared bathroom measured at 111.6 degrees F. LPA observed locked areas where items such as but not limited to, knives, medication, and toxins will be stored inaccessible to clients. LPA toured the back yard and side of house to ensure safety.

Smoke detector and carbon monoxide in operating condition during inspection. LPA observed fully charged fire extinguisher. First aid kit observed to be complete. LPA observed mitigation plan completed. Emergency Disaster Plan last dated on 03/24//2022. Fire drill last conducted on 03/03/2022. LPA reviewed 4 client files.



LPA discussed the Component III with Administrator. Based on observation and interview it appears the facility is ready to be licensed. The report will be forwarded to the centralized application unit for continued processing.

No deficiencies cited during inspection.

Exit Interview conducted with Administrator and a copy of report given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Treana White
LICENSING EVALUATOR SIGNATURE: DATE: 03/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/24/2022
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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