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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607170
Report Date: 09/26/2022
Date Signed: 09/26/2022 11:21:15 AM

Document Has Been Signed on 09/26/2022 11:21 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 HOME 2FACILITY NUMBER:
197607170
ADMINISTRATOR:EDELINA CUAYZONFACILITY TYPE:
735
ADDRESS:13556 DRONFIELD AVENUETELEPHONE:
(818) 332-3557
CITY:SYLMARSTATE: CAZIP CODE:
91342
CAPACITY: 4CENSUS: 4DATE:
09/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Arnulfo CuayzonTIME COMPLETED:
11:30 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 Arnulfo Cuayzon, who allowed LPA to enter. There have not been any active or past COVID cases at the facility, and all staff and (4) clients have been vaccinated with boosters. The current census is (4); (2) clients was out in the community for day program services. LPA’s temperature was immediately taken and documented; a list of COVID-19 questions was asked; 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. The Administrator Edelina Cuayzon was not available for the visit. LPA spoke to Administrator and she was informed the reason of the visit. Administrator provided COVID related questions to LPA via telephone and staff Arnulfo provided the remaining. There is a mitigation plan that was submitted and approved.

The infection control inspection began with the staff Administrator and concluded with staff Arnulfo. The facility has (7) bedrooms; with (4) private rooms for clients, and (3) rooms for staff. All bedrooms were properly furnished. The common areas were observed to be clean, including the (3) bathrooms, with soap and towels. The Administrator reported to LPA, that (4) clients have been vaccinated and recently obtained the booster shot. Only (2) staff are vaccinated. Facility no longer conduct weekly testing, unless staff or clients display any sick related symptoms. Daily temperatures are taken before clients leave the facility and when they return. Any new employee hires will be properly screened, and must be vaccinated prior to employment. Administration continues to conduct training to staff in relation to COVID-19. Administrator reported the facility receives departmental emails. There is currently a paid sick leave policy in place.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE: DATE: 09/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2022
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 2
FACILITY NUMBER: 197607170
VISIT DATE: 09/26/2022
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There are designated rooms for potential positive COVID client, due to the fact, the facility has (3) vacant rooms and each client has a private room. PPE, chemicals, cleaning supplies, emergency food and water, personal hygiene supplies, and paper products are stored in a locked closet. LPA observed a sufficient supply of all items during the visit. LPA observed the facility has Licensing requirement for food supply. Currently, the facility has sufficient staff, and has back-up staff in place if needed. The facility has not had any positive COVID-19 reports for staff or clients. The Administrator informed LPA that they continue to implement the best practices for their facility, which has kept them COVID-19 free. They are strict visitors rules and follow the protocols from public health.

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 was conducted with staff Arnulfo and copy of report provided.

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

DATE: 09/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2022
LIC809 (FAS) - (06/04)
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