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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 04:05:46 PM

Document Has Been Signed on 05/15/2024 04:05 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
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:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:40 PM
MET WITH:Myron Bolden, Administrator TIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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On March 15, 2024 at 1:40 PM, Licensing Program Analyst(LPA) John Calandra arrived at the facility to complete the Annual 1-year required inspection. LPA Calandra was greeted by Myron Bolden, Administrator and explained the purpose of the visit.

All P&I monies kept at the facility match the P&I records for each resident.

The facility did not have a key for R1 and R2s' bedroom. However, in the presence of the LPA, Administrator, Myron Bolden found the key and demonstrated to the LPA that it unlocked R1 and R2s bedroom.

A Technical Violation was provided for not having documentation of the training the licensee and/or staff have completed specific to the needs of the clients.

Two staff and two residents were interviewed during today's visit.

No deficiencies were cited during today's visit.

This report was reviewed with Administrator, Myron Bolten 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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