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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701142
Report Date: 11/18/2022
Date Signed: 11/18/2022 10:38:37 AM

Document Has Been Signed on 11/18/2022 10:38 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:CHOICE MANOR 1FACILITY NUMBER:
342701142
ADMINISTRATOR:DAVIS, EVELYN LYNNFACILITY TYPE:
735
ADDRESS:1609 REMINGTON WAYTELEPHONE:
(209) 334-0570
CITY:LODISTATE: CAZIP CODE:
95242
CAPACITY: 6CENSUS: 4DATE:
11/18/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Elizabeth Davenport - AdministratorTIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced Post-Licensing Inspection Visit. LPA met with Administrator and explained purpose of today’s inspection. Fire clearance licensed for 6 ambulatory clients. The facility administrator’s certificate #6047709735 expires on 04/03/2022.

LPA and administrator toured 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. The hot water was measured at 110.4*F, which is not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). . 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 extinguishers which were last serviced 3/18/2022 . 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 11/2/2022 .



LPA reviewed four (4) client files and four (4) staff files. All staff are fingerprint cleared and have current first aid certificates. All residents have required documents for community care licensing (CCL).

No deficiencies cited per California Code of Regulations, Title 22, Division 6, Chapter 8


Exit Interview conducted with Administrator and a copy of report left at facility.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2022
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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