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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005404
Report Date: 04/02/2024
Date Signed: 04/02/2024 10:33:49 AM

Document Has Been Signed on 04/02/2024 10:33 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
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:
04/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Crystal Hedrick and Soraya Guerrero TIME COMPLETED:
10:45 AM
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On 04/02/2024 Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an annual required inspection at 9:00 AM. LPA Martinez met with Crystal Hedrick and explained the purpose of the visit.

LPA Martinez inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards of the facility to ensure compliance with Title 22 regulations.

Administrator's certificate expired in 12/2023, and recertification application has been submitted to the Department in a timely manner. The recertification application is pending. The facility is licensed for six ambulatory clients. There are currently 6 clients who reside at this facility.

The LPA Martinez toured the facility with Soraya Guerrero on 04/02/2024 at 9:00 AM.

LPA Martinez obtained copies of the Liability insurance, well water system report, and surety bond. LPA Martinez reviewed three staff files and three client files. The files were maintained. The facility has a natural disaster plan, and the last fire drill was on 03/29/2024. The facility has a first aid kit. The fire extinguishers, carbon monoxide detectors, and smoke detectors were in good repair. The exterior emergency exit gate was in good repair. The facility medication cabinet was locked, and LPA Martinez reviewed 1 client medication file. The medication files was complete and maintained. The facility bedrooms and bathrooms were sanitary and furnished. The facility had an adequate food supply. The laundry room was sanitary and the appliances were in good repair.

Based on today's annual inspection, the facility is in compliance with California Code of Regulations, Title 22 and Health and Safety Code, and there were no deficiencies cited at this time. An exit interview was conducted, and a copy of this report was provided to the facility.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 04/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/02/2024
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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