198320185-5-17-2022-11-AS-DSEA-CEJ3KX-20220517181754

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320185
Report Date: 05/17/2022
Date Signed: 05/17/2022 06:18:04 PM

Document Has Been Signed on 05/17/2022 06:18 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, 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: 3	DATE:	05/17/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Licensee - Robin Taporco/Jerissa Buca - Administrator		TIME COMPLETED:	12:22 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 05/17/2022, Licensing Program Analyst (LPA) Don Senaha conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA was met with Licensee Robin Taporco and explained the purpose of today’s visit. The facility is licensed to serve six (6) non-ambulatory elderly residents ages 60 and above of which one (1) can be bedridden in room #4 and has a hospice waiver for four (4). The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) resident's rooms, two (2) bathrooms, living area, dining area, kitchen, and outside shaded patio area. LPA and Licensee 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 water temperature measured between 116.2 F to 119.8 in the bathrooms and kitchen sink. A comfortable temperature was maintained in the facility. There is an attached garage used for storage only. The garage contains an additional food supply, additional refrigerator/freezer for food and washer and dryer. Evaluation Report Continues on LIC 809-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Don Senaha	TELEPHONE: (323) 629-5133
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022

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: 05/17/2022

NARRATIVE

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LPA observed the facility to be appropriately furnished at the time of visit. LPA observed sharps, cleaning supplies and toxins in locked cabinets. The kitchen was inspected and there is sufficient perishable and non-perishable food available and properly maintained. The facility does their grocery shopping every week for food. One (1) fire extinguisher was charged and located in the kitchen area, smoke detectors and carbon monoxide were operable. A review of Medication Administration Records (MAR) was maintained in order and accurate. There was a first aid kit available located with the medications.

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.

Advisory Notes – Two (2) Technical Assistance were issued, please see LIC9102-AN.

There were no deficiencies cited during this inspection visit.

An exit interview was conducted and a copy of this report was provided to Licensee Robin Taporco.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Don Senaha	TELEPHONE: (323) 629-5133
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022

LIC809 (FAS) - (06/04)

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