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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419210022
Report Date: 05/20/2021
Date Signed: 05/21/2021 04:48:43 PM

Document Has Been Signed on 05/21/2021 04:48 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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:CHOICE MANOR IFACILITY NUMBER:
419210022
ADMINISTRATOR:KELCEY HUBBARDFACILITY TYPE:
735
ADDRESS:531 EDGEMAR AVE.TELEPHONE:
(650) 355-8532
CITY:PACIFICASTATE: CAZIP CODE:
94044
CAPACITY: 6CENSUS: 6DATE:
05/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Myron BoldenTIME COMPLETED:
06:00 PM
NARRATIVE
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LPAs Audrey Jeung and Murial Han toured facility and grounds. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, staff training and policies, resident monitoring, containment strategies, environmental preparation and cleaning. PPE supply is adequate. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable temperature is maintained, and lighting is sufficient for comfort and safety. Soap and paper towels are present in bathrooms and kitchen sink. First-aid kit is inspected and complete. A Disaster and Mass Casualty Plan is readily available. There are 6 residents present, and 2 staff. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed. Myron Bolden is a certified ARF administrator (x6/22) that oversees facility operations.

The following forms/information are requested to be updated and submitted to LPA by 6/3/21:

• LIC 308 Designation of Administrative Responsibility
• LIC 309 Administrative Organization
• Proof of current Surety Bond
• LIC 500 Personnel Report
• LIC 610 Emergency Disaster Plan



Deficiency of the ARF California Code of Regulations, Title 22, Division 6, Chapter 8 is observed and cited on a following page.
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE: DATE: 05/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/20/2021
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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Document Has Been Signed on 05/21/2021 04:48 PM - It Cannot Be Edited


Created By: Audrey Jeung On 05/20/2021 at 05:02 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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: CHOICE MANOR I
FACILITY NUMBER: 419210022

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/20/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80072(a)(2)
PERSONAL RIGHTS
Each client shall have personal rights which include, but are not limited to be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.

This requirement is not met as staff are not wearing face coverings, as required by CCLD mandates.
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, as 2 staff present are not wearing face coverings, which poses a potential health, safety or personal rights risk to persons in care.
Each staff and visitor shall wear a face covering, unless an individual's exemption applies, while in the facility. This practice has a health and safety impact that includes, but is not limited to personal rights.
POC Due Date: 06/03/2021
Plan of Correction
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Plan of correction to be submitted to CCLD BY DUE DATE
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Julio Montes
LICENSING EVALUATOR NAME:Audrey Jeung
LICENSING EVALUATOR SIGNATURE:
DATE: 05/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2021


LIC809 (FAS) - (06/04)
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