197610421-7-6-2023-31-AS-ERIS-CTGPWX-20230706114128

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610421
Report Date: 07/06/2023
Date Signed: 07/06/2023 11:42:02 AM

Document Has Been Signed on 07/06/2023 11:42 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	GOODLIFE RESIDENTIAL 3		FACILITY NUMBER:	197610421
ADMINISTRATOR:	NIXON, ALEXIS		FACILITY TYPE:	735
ADDRESS:	15802 SAN FERNANDO MISSION BLV		TELEPHONE:	(323) 445-1522
CITY:	GRANADA HILLS	STATE: CA	ZIP CODE:	91344
CAPACITY: 4		CENSUS: 0	DATE:	07/06/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Alexis Nixon		TIME COMPLETED:	12:00 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 07/06/2023 at 9:45 a.m. Licensing Program Analyst (LPA) Evelin Rios made an announced visit at the facility mentioned above to complete the Pre-Licensing inspection. LPA Rios met with applicant Alexis Nixon and explained the purpose of the visit. The facility is a two story building, with fire clearance granted on 05/12/2023 to serve clients ages 18 through 59 with a capacity of 4, of which all are ambulatory. During today's visit, an inspection of the physical plant was conducted by the applicant and LPA, which consisted of the following: the front of the home, dining room, kitchen, detached garage, common areas, client bedrooms, shared bathrooms, staff room, and laundry area. The facility building and grounds were free from hazards. All walkways were free from debris and/or obstructions. The Emergency Exit plan is posted and readily available for review near the facility entrance/exit. Fire extinguishers were located in the kitchen and in the upstairs hallway by the bedrooms with purchase date of 04/26/2023. They were observed to be fully charged. In the kitchen the stove, oven, and microwave were observed to be operational. There are two refrigerators one located in the kitchen and one in the garage that will be used for extra food supplies. Dishes, cups and flatware are stored in the kitchen cabinets. Knives and all cleaning products are stored and kept locked in a closet under the stairs inaccessible to clients in care. The food supply in the kitchen was observed to have the required 7-day non-perishable foods and 2-day of perishable foods available for the clients. The facility has a two landline telephones observed to be operational, available for client use. The facility is equipped with central air and heat and was at a comfortable 71*F during the time of the visit. Report Continued on LIC809-C...

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023

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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: GOODLIFE RESIDENTIAL 3	FACILITY NUMBER: 197610421
	VISIT DATE: 07/06/2023

NARRATIVE

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Two Restrooms will be shared with one full bathroom upstairs and half bathroom downstairs for client use. Third full bathroom is located inside a bedroom that may be used as a staff room or private use for a client. All were observed to have a working toilet, wash basin and shower. Each bathroom was fully stocked with paper towels and soap for hand washing, and the water temperature in the downstairs bathroom measured 117.8*F degrees.

There are a total of five bedrooms. One bedroom will be designated for staff use. All bedrooms were observed to have sufficient space to accommodate the resident's furnishings, and have all of the required furniture with plenty of personal storage space. Beds have the required linen/supplies which include, pillowcase, fitted sheet, blanket and bedspreads. Each room had an extra supply of linens and a supply of toiletries and personal hygiene items. Extra supply of toiletries were observed in an upstairs hallway closet.

The dining room and living room were observed to be clean and clear of clutter with adequate furniture to sit the capacity of the facility. In the living room LPA observed activity supplies available for client use.

Smoke/carbon monoxide detectors were observed throughout the facility and were tested and operational at 10:08 a.m. The facility also has an emergency alert system that can connect to the fire department, paramedics and local PD. Security system has cameras throughout the facility directed at common areas.

Staff and client files, centrally stored medication and the first aid kit will be kept in a locked walk-in closet by the kitchen inaccessible to clients in care. LPA observed an emergency supply of food stored in the same locked closet.

There are no bodies of water. Backyard has a shaded area with appropriate outdoor furniture for client use.

LPA Rios cleared the physical plant and conducted the Component III Orientation with the applicant. Pre-Licensing is complete and this facility has no deficiencies. An exit interview was conducted and a copy of this report was provided to the applicant.

Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023

LIC809 (FAS) - (06/04)

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