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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397004985
Report Date: 10/15/2024
Date Signed: 11/11/2024 05:12:03 PM

Document Has Been Signed on 11/11/2024 05:12 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:CHOICE MANOR 2 ARFFACILITY NUMBER:
397004985
ADMINISTRATOR/
DIRECTOR:		LORETTA LIVINGSTON-ANTHONYFACILITY TYPE:
735
ADDRESS:7270 SOUTHFIELD WAYTELEPHONE:
(209) 472-9904
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY: 6CENSUS: 4DATE:
10/15/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:02 PM
MET WITH:L. LivingstonTIME VISIT/
INSPECTION COMPLETED:
03:33 PM
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Licensing Program Analyst (LPA) Albert Johnson arrived at facility unannounced to conduct a case management visit. LPA met with Administrator and explained the purpose of today's visit.

The department received an incident report on 10/9/2024 that detailed an aggressive act between two residents.

LPA was able to review the records of the two residents involved and also was able to confirm that the facility has a plan in place to address the aggression that R1 has with additional support during transportation and while residents are transitioning between activities.

This information is found in R1's IPP and his behavior intervention plan.

The facility has conferred with R1's Psychiatrist to adjust medication to assist in calming R1's down and allowing for easier sleep transition.

An exit interview was conducted.

No deficiencies were cited at this time.

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2024
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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