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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397004522
Report Date: 01/12/2022
Date Signed: 01/12/2022 03:58:14 PM

Document Has Been Signed on 01/12/2022 03:58 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 CREEKVIEWFACILITY NUMBER:
397004522
ADMINISTRATOR:SHA GANTFACILITY TYPE:
735
ADDRESS:10539 RUDDER WAYTELEPHONE:
(209) 478-7735
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY: 6CENSUS: 6DATE:
01/12/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:47 PM
MET WITH:Kaira Silva, facility manager, Sha Gant, AdministratorTIME COMPLETED:
04:15 PM
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On 1/12/22 at 1:47pm, Licensing Program Analyst (LPA) Michael Bilger arrived at this facility unannounced to conduct an annual inspection visit. LPA met with the facility manager Kaira Silva and explained the purpose of the visit. Administrator Sha Gant arrived at facility at 2:50pm

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 6 bed adult residential facility with a current census of 6. Facility has 6 bedrooms, 3 bathrooms. 1 bedroom is downstairs, additional bedrooms are upstairs. There is a dining area off the kitchen, a tv room and formal living room.
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. LPA observed the facility to have hand washing, COVID - 19 informational, and social distancing signs posted throughout the facility, on the front door, and back yard. 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. No obstructions to fire exits. Staff records reviewed for Staff1 (S1), S2, S3, S4, S5, S6, and S7. All first aid and COVID-19 vaccinations are current.

Water temperature reads 105.4*F in the bathroom and room temperature reads 69*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 12/2/2021. Facility has an emergency food and water kit.

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was held with Sha Gant and a report was given to Sha.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 01/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/12/2022
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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