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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700647
Report Date: 11/09/2021
Date Signed: 11/09/2021 11:51:06 AM

Document Has Been Signed on 11/09/2021 11:51 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 SLSFACILITY NUMBER:
392700647
ADMINISTRATOR:LORETTA LIVINGSTON-ANTHONYFACILITY TYPE:
735
ADDRESS:3769 POPOLO CIRTELEPHONE:
(209) 851-3925
CITY:STOCKTONSTATE: CAZIP CODE:
95212
CAPACITY: 4CENSUS: 4DATE:
11/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:28 AM
MET WITH:Loretta Livingston-AnthonyTIME COMPLETED:
11:53 AM
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On 11/9/21 at 9:28am, Licensing Program Analyst (LPA) Michael Bilger arrived at this facility unannounced to conduct an annual inspection visit. LPA met with the administrator Loretta Livingston-Anthony and explained the purpose of the visit.

LPA Bilger inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common TV area, and outside backyard of the facility to ensure compliance with Title 22 regulations. Facility is a 4 bed adult residential facility with a current census of 4. Facility has 4 bedrooms and 3 bathrooms. Each resident has a private room. One private room has its own bathroom. No obstructions to fire exits. LPA also conducted the infection control domain tool.
The facility has an approved COVID Mitigation plan LIC 808 form in place. The facility has central entry point and has implemented screening and sign in procedures at the front door area. The facility conducts routine symptom screening for employees, residents, and visitors. The facility has a designated infection control lead. The facility is able to designate and dedicated a Covid-19 room/bathroom if needed. Common touch surfaces are cleaned after each use.

Water temperature reads 109.7*F in the bathroom and room temperature reads 71*F. LPA observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguisher was checked 6/1/21. Facility has an emergency food and water kit.

Per California Code of Regulations, Title 22, deficiencies were observed during this visit and noted on LIC 809D. An exit interview was held with Loretta Livingston-Anthony and a copy of this report was given to Administrator Loretta Livingston-Anthony.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 11/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2021
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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Document Has Been Signed on 11/09/2021 11:51 AM - It Cannot Be Edited


Created By: Michael Bilger On 11/09/2021 at 11:17 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: CHOICE SLS

FACILITY NUMBER: 392700647

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/09/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80072(a)(2)
Personal Rights
(a) Each client shall have personal rights including: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.

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. Facility did not have appropriate COVID-19 signage on entry way door and throughout facility including but not limited to: Visitor safety and precautions, signs and symptoms of illness, cough ettiquete, and handwashing protocols, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/12/2021
Plan of Correction
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Licensee will post all appropriate COVID-19 signage at entry way and throughout facility and provide photo or video proof to LPA by POC due date.
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:Liza King
LICENSING EVALUATOR NAME:Michael Bilger
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2021


LIC809 (FAS) - (06/04)
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