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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397004985
Report Date: 11/09/2021
Date Signed: 11/09/2021 03:10:10 PM

Document Has Been Signed on 11/09/2021 03:10 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 MANOR 2 ARFFACILITY NUMBER:
397004985
ADMINISTRATOR:LORETTA LIVINGSTON-ANTHONYFACILITY TYPE:
735
ADDRESS:7270 SOUTHFIELD WAYTELEPHONE:
(209) 472-9904
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY: 6CENSUS: 4DATE:
11/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Loretta Livingston-AnthonyTIME COMPLETED:
03:20 PM
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On 11/9/2021 at 1:05pm Licensing Program Analyst (LPA) Ashley Boothe arrived unannounced to conduct a Required 1-year Annual Inspection. LPA COVID screened upon entry with staff one (S1) who confirmed no staff or residents have tested positive or shown symptoms within the past 10 days. LPA met with Administrator who arrived on cite shortly after LPA's arrival. LPA was allowed entry into the facility that is licensed to serve a total capacity of 6, today's census is 4. Three of three staff observed on site with criminal record clearance in Licensing Information System. LPA observed Administrator Certificate expires on 4/6/2023.

LPA interacted with a random number of residents during this visit and observed residents engaged in activities and group outing. The physical plant was toured inside and outside to ensure the safety of the residents. LPA observed kitchen, restrooms, bedrooms, storage areas, and common living areas to be clean and in good repair. The temperature inside the facility was measured at 72*F which is within the required range of 68*F and 85*F, or in areas of extreme heat the maximum shall be 30*F less than the outside temperature. The hot water was measured at 113*F within regulatory range of is not less than 105*F and not more than 120*F. LPA observed the centrally stored medications, toxins and knives to be locked inaccessible to residents. The first aid kit observed in compliance containing at least the following: a current edition of an approved first aid manual, sterile first aid dressings, bandages or roller bandages, adhesive tape, tweezers, scissors, thermometers, and Antiseptic solution.

Facility handles P & I monies, LPA observed the log is maintained and there is no commingling of funds. LPA observed the facility conducts fire drills documented monthly.

Continued on 809 C.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Ashley Boothe
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)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 2 ARF
FACILITY NUMBER: 397004985
VISIT DATE: 11/09/2021
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Continued from 809.

LPA observed fire extinguisher last inspected on 7/19/2021, smoke and carbon monoxide detectors, central heating and air in the facility. LPA observed food supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days which shall be maintained on the premises at all times. LPA observed COVID precautions signs posted, restrooms stocked with hand soap, hand washing signs, paper towels, and touchless covered trash cans. LPA observed 30 day supply of PPE stored is stored.

The facility has an approved Mitigation Plan.

Upon a file review the following items were discussed to be submitted to LPA by 11/20/2021:
Designation of Administrative Responsibility LIC308
Qualifications of Administrator
Personnel Report LIC500
Surety Bond LIC402
Emergency Disaster Plan LIC610D

Per California Code of Regulations (CCRs) - Title 22, no deficiencies observed or cited. Exit interview held and a copy of report provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Ashley Boothe
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
LIC809 (FAS) - (06/04)
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