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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005404
Report Date: 02/22/2022
Date Signed: 02/23/2022 08:48:00 AM

Document Has Been Signed on 02/23/2022 08:48 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 HARNEY ARFFACILITY NUMBER:
397005404
ADMINISTRATOR:CRYSTAL HEDRICKFACILITY TYPE:
735
ADDRESS:12436 E. HARNEY LANETELEPHONE:
(209) 333-3913
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY: 6CENSUS: 6DATE:
02/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Crystal Hedrick, AdministratorTIME COMPLETED:
01:15 PM
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At 11:35 AM, LPA T. White arrived unannounced to conduct a required 1-year Annual inspection. LPA met with Administrator, Crystal Hedrick. LPA explained the purpose of today’s inspection. LPA was allowed entry into the facility that is licensed to serve a total capacity of 6 clients.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature for clients is maintained at 68 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 113.4 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. There is a minimum of 7-day nonperishables and 2-day perishables foods.

Smoke detectors and carbon monoxide were in operating condition during inspection. Fire extinguisher was last serviced on March 03, 2021. Emergency Disaster Plan was last posted on 03/03/2021. Mitigation observed to be complete. First aid kit was observed to be complete. Fire drill was last conducted on 02/10/2022.
The following forms to be updated and submitted to CCLD by 03/04/2022:
LIC 500 Personnel Report
LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 400 Affidavit Regarding Client/Resident Cash Resources
LIC 402 Surety Bond
LIC 610E Emergency Disaster Plan
Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies observed or cited.
Exit interview conducted with Administrator, copy of report given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Treana White
LICENSING EVALUATOR SIGNATURE: DATE: 02/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/22/2022
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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