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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606511
Report Date: 03/24/2022
Date Signed: 03/24/2022 10:09:28 AM

Document Has Been Signed on 03/24/2022 10:09 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:GOODLIFE RESIDENTIAL HOMEFACILITY NUMBER:
197606511
ADMINISTRATOR:ALEXIS NIXONFACILITY TYPE:
735
ADDRESS:13888 SHABLOW AVENUETELEPHONE:
(818) 362-4420
CITY:SYLMARSTATE: CAZIP CODE:
91342
CAPACITY: 4CENSUS: 3DATE:
03/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Dominga ReynanteTIME COMPLETED:
10:25 AM
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Licensing Program Analyst (LPA) Tuesday Cabiness arrived at the facility to conduct an unannounced infection control inspection/visit. Upon entry, LPA was greeted by staff Dominga Reynante, who allowed LPA to enter. There have not been any active or past COVID cases at the facility, and all staff and clients are vaccinated; including the booster shot. The current census is (4); but only (3) were present during the visit. LPA’s temperature was immediately taken and documented; and LPA signed in the visitor book. LPA observed staff to have full mask covering; a hand sanitizing station; PPE supplies in drawer; and COVID-19, CDC, Department of Public Health, and Licensing postings on the walls throughout the facility. LPA discussed the mitigation plan that was submitted and approved with staff Dominga.

The facility has (5) bedrooms and (3) bathrooms; with (4) private rooms, and (1) room for staff. The common areas were observed to be clean, including bathrooms, with soap and towels. LPA conducted a mitigation plan review with the staff Dominga in order to obtain information on how the facility has implemented the plan. Currently, the facility only COVID test when there are signs or symptoms from clients or staff. The Licensee receives departmental emails and forwards them to staff at the facility to keep everyone notified on COVID-19 procedures. Staff Dominga informed LPA that if facility staff become ill with COVID symptoms, the Licensee has hotel accommodations and staff would be paid there regular salary while on leave.

There are designated rooms for potential positive COVID clients; there are (5) private rooms available. PPE, chemicals, cleaning supplies, water, personal hygiene supplies, and paper products are stored in the garage area. LPA observed a sufficient supply of all items during the visit. LPA observed the facility has Licensing requirement for food supply.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE: DATE: 03/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/24/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: GOODLIFE RESIDENTIAL HOME
FACILITY NUMBER: 197606511
VISIT DATE: 03/24/2022
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Currently, the facility has sufficient staff, and has back-up staff in place if needed. The facility has not had any positive COVID-19 reported since the beginning of the pandemic. Staff informed LPA that they continue to implement the best practices for their facility, which has kept them COVID-19 free. The facility is aware to report any changes with clients and staff to Licensing and there LPA, pertaining to positive COVID-19 cases.

Exit interview and copy of report will be emailed to the Licensee.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2022
LIC809 (FAS) - (06/04)
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