198320298-8-16-2022-11-AS-PSCT-CHCPFL-20220816111656

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320298
Report Date: 08/16/2022
Date Signed: 08/16/2022 11:17:12 AM

Document Has Been Signed on 08/16/2022 11:17 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	SWEET LIFE COTTAGE		FACILITY NUMBER:	198320298
ADMINISTRATOR:	BUCU, JERISSA MARIE		FACILITY TYPE:	740
ADDRESS:	909 W.232ND ST.		TELEPHONE:	(424) 263-2246
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90502
CAPACITY:	6	CENSUS: 6	DATE:	08/16/2022
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Jarissa Bucu		TIME COMPLETED:	11:20 AM

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 08/16/22, Licensing Program Analyst (LPA) Perry Scott/LPM Janae Hammond conducted an announced visit to this facility for the purpose of pre-licensing. We were greeted by administrator Jerissa Bucu and Jonna Lamb (admin) explained the purpose of today’s pre-licensing inspection visit. An application was submitted to CCLD on 07/01/22 in the initial license application for a Residential Facility for the Elderly, ages 60 years and above. The applicant requested a capacity of six (6) individuals, of which may be five (5) non-ambulatory, and one (1) bedridden; with a hospice waiver for 4. Structure: The home is a four (4) bedroom, three (3) bathroom, one-story home with a one (1) car garage situated in a residential neighborhood. The home includes a living, dining, kitchen, and laundry area. The living area included recliners and a table. The kitchen has a refrigerator and stove. The rear exterior is fenced throughout. The passageways, walkways, and steps are free from obstructions. Bedrooms Residents: The facility has four (4) bedrooms for residents and staff. Bedroom #1 is approved for one (1) non-ambulatory and one (1) bedridden. Bedroom # 2 is approved for two (2) non-ambulatories. Bedroom # 3 is approved as a staff bedroom. And bedroom # 4 is approved for two non-ambulatory residents. All rooms include a full- or twin-size bed, one (1) chair, one (1) nightstand, and one (1) table lamp. All bedrooms are equipped with a ceiling light. All rooms had a dresser, which complies with the requirement of 8 cubic feet of space. All rooms had closets for ample storage. Evaluation Report Continues

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Perry Scott	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2022

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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SWEET LIFE COTTAGE	FACILITY NUMBER: 198320298
	VISIT DATE: 08/16/2022

NARRATIVE

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Bedrooms Staff:
There is one bedroom designated for live-in staff.

Bathrooms:
The home has three (3) bathrooms. Bathrooms are accessible in all rooms. All bathrooms have a working toilet, washbasin, and shower with grab bars and non-skid mats.

Linens & Hygiene Supplies:
Beds have the required linen supplies which include, pillowcases, mattress pads, fitted sheets, blankets, and bedspreads. An adequate supply of linen is stored in the garage storage are.

Emergency Phone Numbers, Exit Plan & Menu:
Emergency phone numbers. The exit plan and menu are posted and readily available for review throughout the home. There are two (2) fire extinguishers located in the kitchen mounted on the wall, as well as in the garage. A telephone line is available in the kitchen, living, and dining rooms. Emergency supplies and Personal Protective Equipment supplies are stored in the garage. The applicant submitted a Mitigation Plan on 02/04/22.

Food Service:
Dishes, cups, and flatware are stored in the kitchen cabinets, inspected, and in good repair. Knives, cutlery, and other sharp kitchen utensils are stored in a locked drawer. Food supply is adequately stored in kitchen cabinets and consists of boxed and can goods. The kitchen counters also had small appliances.

Smoke Detectors:
Smoke and carbon monoxide detectors throughout the interior space. Hardwired smoke detectors in all four (4) bedrooms and hallways. Carbon monoxide is combined with smoke detectors

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Perry Scott	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2022

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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SWEET LIFE COTTAGE	FACILITY NUMBER: 198320298
	VISIT DATE: 08/16/2022

NARRATIVE

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Toxins:
All toxins are locked and stored under the kitchen sink cabinet and in the garage.

Evaluation Report Continues

Stove burners, oven, microwave, washer, and dryer are working. The kitchen counters also had small appliances which include an instapot and air fryer. There is one (1) refrigerator in the home. The home is equipped with central heaters and air conditioning systems.

Water Temperature:
The water temperature is 118.7 degrees throughout the kitchen and bathrooms.

Medications, First-Aid Kit & Book:
A first aid kit is stored in the medication cabinet. It was inspected and has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze, and current first aid manual locked and inaccessible to residents. The resident’s medications will be stored in the same medication cabinet locked in the dining area and inaccessible.

Resident & Staff Files:
The applicant is not handling the cash resources for residents. Records of staff and residents will be stored in a cabinet in the dining area.

Reading Material, Games, Equipment & Materials:
The facility has board games, books, magazines, and other recreational materials for the resident's use all stored in the living room.

Pool/Jacuzzi & Pets:
There are no pets, jacuzzi, or pools on the premises.

Evaluation Report Continues

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Perry Scott	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2022

LIC809 (FAS) - (06/04)

Page: 3 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SWEET LIFE COTTAGE	FACILITY NUMBER: 198320298
	VISIT DATE: 08/16/2022

NARRATIVE

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Fire clearance:
A Fire Clearance inspection was conducted on 06/03/22 approved for a capacity for five (5) non-ambulatory, and one (1) bedridden.

Component III:
LPM Hammond/LPA Scott conducted the Pre-Licensing inspection along with the information provided about how to operate the facility within substantial compliance with Component III PowerPoint.

LPA observed no deficiencies that needed to be corrected during this pre-licensing inspection.

An exit interview was conducted, and a copy of this report has been furnished to the administrator, Jerissa Bucu. LPA Scott 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.

END OF REPORT

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Perry Scott	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2022

LIC809 (FAS) - (06/04)

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