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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419210022
Report Date: 05/15/2024
Date Signed: 05/15/2024 12:20:00 PM

Document Has Been Signed on 05/15/2024 12:20 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:CHOICE MANOR IFACILITY NUMBER:
419210022
ADMINISTRATOR/
DIRECTOR:
MYRON X BOLDENFACILITY TYPE:
735
ADDRESS:531 EDGEMAR AVE.TELEPHONE:
(650) 355-8532
CITY:PACIFICASTATE: CAZIP CODE:
94044
CAPACITY: 6CENSUS: 5DATE:
05/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Rebecca Pineda, Direct Support Professional and Joel Pelletier, Direct Support Professional and Transportation TIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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On May 15, 2024 at 8:45 AM, Licensing Program Analyst(LPA) John Calandra arrived at the facility to conduct the Annual 1-year required visit. LPA Calandra was greeted by Rebecca Pineda, Direct Support Professional(DSP). Rebecca called Myron Bolden, Administrator but Myron was unable to join the visit. Direct Support Professional, Joel Pelletier Sr. arrived later during the visit.

LPA Calandra toured the physical plant. This is a 1-story building that consists of 4 bedrooms, 2 bathrooms, a kitchen, garage, living room, office, and dining room. The facility was maintained at a comfortable temperature of 72 degrees Fahrenheit. Fire extinguishers were last checked on 7/6/2023. All bedrooms had the required furniture and sufficient lighting. No hazards or obstructions were present in the hallways, backyards, and front yard. The washer and dryer were observed to be in working condition. The facility has active phone service. Water temperature was measured within the required range of 150-120 degrees Fahrenheit.

A review of Centrally stored medications indicated that medications for residents were properly labeled with instructions on dosage and times of day and matched the Centrally Stored Medication Records(CSMR) kept at the facility.

LPA reviewed 5 resident records and 4 staff records. All were observed to be complete.

All knives, sharp objects, detergent, and soap were observed to be locked up and in-accessible to persons in care.

No deficiencies were cited during today's visit. The Annual will be completed at a later date.

This report was reviewed with Joel Pelletier Sr. and a copy of the report left at the facility.
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE: DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/15/2024
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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