198320185-5-18-2021-11-AS-ASOO-C35QJH-20210518121245

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320185
Report Date: 05/18/2021
Date Signed: 05/18/2021 12:12:50 PM

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 SENIOR CARE		FACILITY NUMBER:	198320185
ADMINISTRATOR:	TAPORCO, ROBIN		FACILITY TYPE:	740
ADDRESS:	23741 KIPPEN ST		TELEPHONE:	(408) 916-7347
CITY:	HARBOR CITY	STATE: CA	ZIP CODE:	90710
CAPACITY:	6	CENSUS: 6	DATE:	05/18/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Robin Taporco, Licensee		TIME COMPLETED:	12:30 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 Analysts (LPA) Ana Soto, conducted a announced visit to the facility for the purpose of a Pre-Licensing evaluation. An application was submitted to Community Care Licensing Department (CCLD) on 02/12/2021 for an initial license for an Residential Facility to serve Elderly for ages 60 and above years. The requested capacity is for (6) Residents, 5 Non - Ambulatory and 1 - Bedridden. Today’s pre-licensing was conducted with Robin Taporco, the facility Licensee. An application was submitted to Community Care Licensing Department (CCLD) on 02/12/2021 for an initial license for an Residential Facility to serve Elderly for ages 60 and above years. The requested capacity is for (6) Residents, 5 Non - Ambulatory and 1 - Bedridden.Community Care Licensing Department (CCLD) on 02/12/2021 for an initial license for an Residential Facility to serve Elderly for ages 60 and above years. The requested capacity is for (6) Residents, 5 Non - Ambulatory and 1 - Bedridden.: Facility structure is a four (4) bedrooms, and two (2) full bathrooms, single story house with small front porch, attached 2 car garage. The facility is a yellow stucco structure with rear patio and small backyard. Front yard landscape is in great condition. Rear patio patio has 1 table, 6 chairs, and pergola. There are 2 small ramp.: 1st is outside of room #4 and 2nd is outside Room #2. Signal System : Delayed egress signal system in facility is operational. Bedroom Residents : There shall be no more than two residents per bedrooms. The bedrooms are designated resident bedrooms properly equipped with regulation guidelines of 1 bed, 1 chair, 1 night stand, 1 lamp and overhead lighting. The 2 bedrooms will be private bedrooms for 1 resident per bedroom. 2 Bedroom are shared bedrooms, no more than 2 residents per bedroom. No bedrooms will be used for awake staff. Bathrooms: 1st full bathroom is located near bedrooms and 2nd is located in room #4. All bathrooms have a working toilet and wash basin and a walk-in shower, folding bench, mat, and hand rails. Linens & Hygiene Supplies: Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen is stored in hallway closets.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2021

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 SENIOR CARE	FACILITY NUMBER: 198320185
	VISIT DATE: 05/18/2021

NARRATIVE

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Emergency Phone Numbers , Exit Plan, & Menu: Emergency numbers and menu are posted and readily
available for review in hallway wall. Facility has a land line telephone. 1 Fire extinguisher is which is labeled,
they are tagged with current annual check. Food Service : Dishes, cups, and flatware are stored in the kitchen, cupboards, inspected and in good repair. Knives, cutlery, and other sharp kitchen utensils are stored in locked storage drawers in the kitchen cabinets. Adequate food supply is stored in kitchen, and consists of the following: 2 day perishables, and 7 week non-perishables. Dishwasher in kitchen is properly installed and
functioning. Smoke Detectors : There are 5 hard wired smoke detectors, and dual operated carbon monoxide
detector located in the hallway, all are operational. Appliances : Stove burners, oven, microwave, and
washer/dryer are in working condition. There is one refrigerator in the home. The residence is equipped with
central heat and air conditioning. Toxins: Cleaning supplies, and toxins are stored beneath the kitchen sink
and locked cabinet. Water Temperature : Water was tested in kitchen sink within 105-120 degrees Fahrenheit range. Medication and First-Aid Kit & manual: Designated area for centrally stored medication is located near the kitchen pantry with lock. A first-aid kit has been inspected which has at least the following: thermometer, tweezers ,scissors, antiseptic, bandages, gauze and current first aid manual, which are stored with medication in the kitchen pantry, available for staff use, but inaccessible to residents. Residents & Staff Files: Designated area for files will be located in the Kitchen pantry with a lock. Pools/Jacuzzi & Pets : Nobodies of water and no pets on these premises. Fire Clearance: Fire clearance does indicate delayed egress or any locked perimeter. Component III: Conducted at the Pre-Licensing visit.

No corrections needed.

An exit interview was conducted and a copy of this report has been furnished to the applicant. Accordingly,
LPA will submit a copy of this facility evaluation report to the Central Applications Unit (CAU) for review. If the
applicant has questions regarding the status of the application, they have been instructed to communicate
with the CAU Analyst assigned to their application.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2021

LIC809 (FAS) - (06/04)

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