197608239-12-2-2023-11-AS-ARID-CY5S9N-20231202124102

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608239
Report Date: 12/02/2023
Date Signed: 12/02/2023 12:41:09 PM

Document Has Been Signed on 12/02/2023 12:41 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
EL SEGUNDO ASC, 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:	12/02/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:02 AM
MET WITH:	Robinlynn Taporco		TIME COMPLETED:	01:00 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 12/02/2023, Licensing Program Analyst (LPA) Antonine Richard conducted an unannounced annual required visit using the new CARE Inspection Tool. LPA was met by caregiver Edgardo Baylon and later joined by Administrator Jerissa Bucu 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 Richard 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 hot water temperature measured between 111.8F and 112.0F for both bathrooms. 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: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Antonine Richard	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 12/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SWEET LIFE GUEST HOME	FACILITY NUMBER: 197608239
	VISIT DATE: 12/02/2023

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
26
27
28
29
30
31
32

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 stored properly. 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. The last fire drill was 11/11/2023.

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.

No deficiencies were cited during this inspection visit.

Exit interview conducted and a copy of the report was provided to administrator Jerissa Bucu

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Antonine Richard	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 12/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2