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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610421
Report Date: 10/16/2024
Date Signed: 10/16/2024 01:52:06 PM

Document Has Been Signed on 10/16/2024 01:52 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:GOODLIFE RESIDENTIAL 3FACILITY NUMBER:
197610421
ADMINISTRATOR/
DIRECTOR:		NIXON, ALEXISFACILITY TYPE:
735
ADDRESS:15802 SAN FERNANDO MISSION BLVTELEPHONE:
(323) 445-1522
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY: 4CENSUS: 4DATE:
10/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Alexis Nixon, Mary HipolitoTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Michael Cava conducted an Annual Required visit and inspection of the facility. LPA met with the administrator, Alexis Nixon, and staff, Mary Hipolito, and explained the reason for the visit.

At approximately 11:00 am, with the assistance of staff, LPA took a tour of the physical plant. The facility is a two story building, licensed to serve four (4) ambulatory residents only, age 18-59. The smoke alarms are inter-connected. There are three functional carbon monoxide detectors (two in first floor, one in second) that are functional. There are two fire extinguishers. One is located by the kitchen, and the other is located in the second floor hallway. The fire extinguishers were purchased on 06/14/24 and 07/06/24. Heating and cooling is centralized and controls are located in the hallway on the second floor. Interior temperature is 72 degrees for the day. There is a locked closet on the first floor, where cleaning supplies are kept.

Kitchen: The kitchen appliances and fixtures appear to be functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen. Extra emergency food supply kept locked in the medication room.

Bedrooms: There are five (5) bedrooms. Four (4) are designated for residents' use, and one is for staff. Bedrooms #1 to #4 are for resident use. All four bedrooms are private. All bedrooms were observed to be properly furnished with appropriate beddings and linens with sufficient lighting. Bedroom #5 is designated for staff.

Bathrooms: There are two and a half (2 1/2) bathrooms designated for residents' use. The half bathroom, with toilet and sink, is located in the first floor. It can be used by both residents and staff. The full bathroom, with shower, toilet and sink, for resident use is on the second floor. There is a bathroom schedule for
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE: DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/16/2024
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 3
FACILITY NUMBER: 197610421
VISIT DATE: 10/16/2024
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resident showers, posted outside. The resident bathroom is properly supplied and had functional fixtures. The second full bathroom, is located in staff room (Room #5). Hot water temperature in the bathrooms designated for resident use was measured between 107 and 113 degrees Fahrenheit. No cleaning supplies were observed in either bathrooms during the day of the inspection.

Common Areas: These included the living room and dining area. The living room was furnished with two couches, chair, bookshelf for board games, and television. There were two dining areas. Both dining areas had a table each, large enough to seat up to six (6) individuals. Furniture in common areas were clean and in good repair. Floors were mopped and clean. Hallways and passageways were clear of any obstruction. Cameras to be installed in common areas. Administrator will submit addendum for the program plan to CCL the week of 10/21/24, prior to installation.

Surrounding Grounds: Entry/exits to the front and back yards were free of obstruction. No locks at either side gates. There was furniture appropriate for outdoor use. The backyard has sufficient space to hold outdoor activities. There are no pools or any other bodies of water.

Laundry area: The laundry area is on the second floor. It was locked during the day's visit.

Resident Files: Resident files are kept locked in the medication room. LPA conducted a file review of resident records to insure compliance of licensing forms.

Staff Files: Staff files are also kept locked in the medication room. LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms.

Medications: Medication room is located in between the kitchen and dining room. It is kept locked at all times. Medications were reviewed for proper storage and documentation.

Garage: The garage is not connected to the building. It is located in the backyard. Garage is used for extra storage. It is kept locked at all times.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, no deficiencies observed during the visit. Exit Interview Conducted and a copy of this report issued.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024
LIC809 (FAS) - (06/04)
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