197608239-7-25-2022-11-AS-DSEA-CGP39K-20220725180313

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608239
Report Date: 07/25/2022
Date Signed: 07/25/2022 06:03:32 PM

Document Has Been Signed on 07/25/2022 06:03 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	SWEET LIFE GUEST HOME		FACILITY NUMBER:	197608239
ADMINISTRATOR:	JERELYN TAPORCO		FACILITY TYPE:	740
ADDRESS:	1461 WOODBURY DRIVE		TELEPHONE:	(424) 263-4255
CITY:	HARBOR CITY	STATE: CA	ZIP CODE:	90710
CAPACITY:	6	CENSUS: 6	DATE:	07/25/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:43 AM
MET WITH:	Administrator - Jerelyn Taporco		TIME COMPLETED:	12:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 07/25/2022, Licensing Program Analyst (LPA) Don Senaha conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA was met by caregiver Estalina Baylon and later joined by Administrator Jerelyn Taporco and explained the purpose of today’s visit. The facility is licensed to serve six (6) elderly residents ages 60 and above of which five (5) can be non-ambulatory, one (1) can be bedridden and one (1) can be on hospice care. The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) resident's rooms, a staff room, two (2) bathrooms, living area, dining area, kitchen, and outside shaded patio area with ample seating in backyard. LPA and caregiver Edgardo Baylon toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting provided, storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were operational. The water temperature measured between 107.8 F and 108.7 F for both bathrooms and kitchen sink. A comfortable temperature was maintained in the facility. There is a detached garage used for storage only. The garage contains an additional refrigerator/freezer for food and additional pantry area. The garage also is where the washer and dryer are located for laundry. Evaluation Report Continues on LIC 809-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Don Senaha	TELEPHONE: (323) 629-5133
LICENSING EVALUATOR SIGNATURE:	DATE: 07/25/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2022

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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SWEET LIFE GUEST HOME	FACILITY NUMBER: 197608239
	VISIT DATE: 07/25/2022

NARRATIVE

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LPA observed the facility to be appropriately furnished at the time of visit. LPA observed cleaning supplies and toxins not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available and properly maintained. Grocery shopping for the facility takes place every Tuesday and Saturday of the week. There is one (1) fire extinguisher fully charged in the kitchen area. Smoke detectors and carbon monoxide were tested and operational. A review of Medication Administration Records (MAR) was maintained in order and accurate. There was a first aid kit available stored near the medications.

During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

Advisory Notes – Two (2) Technical Assistance were issued, please see LIC9102-AN.

There was one (1) deficiency cited during this inspection visit. See 809D page.

An exit interview was conducted and a copy of this report was provided to Administrator Jerelyn Taporco.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Don Senaha	TELEPHONE: (323) 629-5133
LICENSING EVALUATOR SIGNATURE:	DATE: 07/25/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/25/2022 06:03 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SWEET LIFE GUEST HOME	FACILITY NUMBER: 197608239
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. There was a knife left in the dish rack unsecured and a scissors left out on kitchen counter which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/25/2022
	Plan of Correction
1 2 3 4	Licensee immediately locked both the knife and scissors in a cabinet. Licensee to retrain staff via in-service training.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Don Senaha	TELEPHONE: (323) 629-5133
LICENSING EVALUATOR SIGNATURE:	DATE: 07/25/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2022

LIC809 (FAS) - (06/04)

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