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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005404
Report Date: 10/22/2022
Date Signed: 10/22/2022 02:05:37 PM

Document Has Been Signed on 10/22/2022 02:05 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 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:
10/22/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Bola SanyaoluTIME COMPLETED:
02:00 PM
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LPA Johnson arrived at the care facility and met with House manager to conduct a case management visit into an incident report received into the department on 9/29/2022.

Without warning, and or identified antecedent R1 became physically aggressive toward staff and was redirected outside by staff. Staff used Pro-Act techniques to de-escalate the situation and help R1 to regain control of his maladaptive behaviors. R1 returned to baseline and was without incident for the remainder of the evening.

Facility has a first aid kit and centrally stored locked medication. The facility has adequate lighting throughout. All bedrooms inspected have appropriate furnishings, chair, adequate lighting and storage.

Smoke detectors and carbon monoxide detectors were checked and operational. Fire extinguisher indicator revealed a full charge. Kitchen is clean and in good repair. The kitchen has operable appliances. There is a locked area for cleaning supplies and toxins. The 7 day non-perishable food requirement is met.

This is a level 4-I negotiated rated home, R1 has lived at this facility for 9 years.

No deficiencies were cited today.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 10/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/22/2022
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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