197610421-8-7-2025-31-AS-MCAA-DKBSKZ-20250807135733

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610421
Report Date: 08/07/2025
Date Signed: 08/07/2025 01:58:55 PM

Document Has Been Signed on 08/07/2025 01:58 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 3		FACILITY NUMBER:	197610421
ADMINISTRATOR/ DIRECTOR:	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: 4	DATE:	08/07/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:02 AM
MET WITH:	Alexis Nixon, Mary Hipolito		TIME VISIT/ INSPECTION COMPLETED:	02:00 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	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 9:15 am, 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 04/17/25. Heating and cooling is centralized and controls are located in the hallway on the second floor. There is a locked closet on the first floor, where cleaning supplies are kept. There are four cameras installed in common areas (dining room, kitchen, stairs, living room). No audio. Lenses are directed at common/public spots only. Emergency drill last conducted 07/25/25. Kitchen: The kitchen appliances and fixtures appear to be functional. LPA observed a sufficient amount of perishable and non-perishable food properly stored. Knives are locked in a drawer. Extra emergency food supplies kept locked in the medication room. Bedrooms: There are five (5) bedrooms. Four (4) are designated for residents, and one is for staff. Bedrooms #1 to #4 are for resident use. All four bedrooms are private and observed to be properly furnished with appropriate beddings and linens with sufficient lighting. Bedroom #5 is designated for staff.

NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Michael Cava
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: 08/07/2025

NARRATIVE

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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, are for both staff and residents. The two full bathrooms are on the second floor. The bathroom designated for resident use is in the hallway. It is properly supplied and had functional fixtures. The second full bathroom, is located in staff room (Room #5). Hot water temperature was measured between 105 and 107 degrees Fahrenheit.

Common Areas: These included the living room and dining area. Living room furniture were clean and in good repair. The fireplace, which is never in use, is still properly screened. There were two dining areas. Both dining areas had a table each, large enough to seat up to six (6) individuals. Floors in the living and dining room were mopped and clean.

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 and 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.

NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Michael Cava
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2025

LIC809 (FAS) - (06/04)

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