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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397004985
Report Date: 03/06/2024
Date Signed: 03/06/2024 04:28:36 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 03/06/2024 04:28 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:LORETTA LIVINGSTON-ANTHONYFACILITY TYPE:
735
ADDRESS:7270 SOUTHFIELD WAYTELEPHONE:
(209) 472-9904
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY: 6CENSUS: 4DATE:
03/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Kolesha Farries, AdministratorTIME COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Renee Campbell made an unannounced visit to this facility to conduct an annual inspection on 03/06/24 at 1:15 pm. LPA Campbell met with Administrator Kolesha Farries and stated the purpose of today’s visit. The Administrator's certificate is # 6061348735 and will expire on 08/05/24.

This facility is a two story building licensed for 6 ambulatory developmentally delayed adults between the ages of 18 and 59. At this time, there is a census of 4 adult residents. LPA Campbell observed one resident in the living room watching tv and one resident sleeping in his room due to a recent dental extraction. Another two residents were observed by LPA Campbell returning to the facility from day program at approximately 2:30 pm.

LPA Campbell toured the Facility with Eva McDowell, Direct Service Provider on 03/06/24 and observed that the facility was clean and odor free. LPA Campbell inspected the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms, resident bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations.

LPA Campbell toured the kitchen and observed sufficient seven-day non-perishable and two-day perishable foods. LPA observed the centrally stored medications, toxins and knives in the kitchen to be locked and inaccessible to residents.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 03/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/06/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 ARF
FACILITY NUMBER: 397004985
VISIT DATE: 03/06/2024
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The first aid kit was 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.

The refrigerator temperature was measured at 44 degrees Fahrenheit which is below the required maximum of 45 degrees Fahrenheit. The freezer was set at -5 degrees Fahrenheit, below the maximum of 0 degrees Fahrenheit. A thermostat was observed set at 69 degrees Fahrenheit which is between the required temperatures of 68 and 85 degrees Fahrenheit. The hot water temperature was measured at 110 degrees Fahrenheit in the kitchen within the regulation of 105 to 120 degrees Fahrenheit. Grab bars and non-slip mat were observed to be stable and in good repair at this time. Smoke and carbon monoxide detectors were tested and are in compliance with fire safety. The fire extinguisher is located in kitchen and upstairs in the linen cabinet and was last serviced on 03/14/2023 and was fully charged. During a tour of the backyard, LPA Campbell observed that two storage sheds containing chemicals, paint and yard equipment were left unlocked.

As a result of this annual visit, the facility is not in compliance with Title 22 Regulation, and the deficiencies can be found on the LIC 809 D page. An exit interview was conducted, and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the facility.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/06/2024 04:28 PM - It Cannot Be Edited


Created By: Renee Campbell On 03/06/2024 at 03:47 PM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: CHOICE MANOR 2 ARF
FACILITY NUMBER: 397004985

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/15/2024
Section Cited
CCR
80087(a)

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80087(a) Buildings and Grounds- The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by
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The administrator/ licensee will lock the two sheds in the backyard so that they are inaccessible to clients in care. Once an image of the locked sheds are sent to LPA Campbell at renee.campbell@dss.ca.gov by POC date, the citation will be cleared.
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Based on observations, the licensee did not lock the outdoor storage shed and provide a clean, safe, sanitary environment for clients, employees and visitors. This poses a potential, health, safety or personal rights risk to persons in care.
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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:Lisa Rios
LICENSING EVALUATOR NAME:Renee Campbell
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2024


LIC809 (FAS) - (06/04)
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