198320298-11-22-2023-11-AS-EGOZ-CXTT8T-20231122133052

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320298
Report Date: 11/22/2023
Date Signed: 11/22/2023 01:30:56 PM

Document Has Been Signed on 11/22/2023 01:30 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
EL SEGUNDO ASC, 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: 5	DATE:	11/22/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:19 AM
MET WITH:	Jerissa Bucu		TIME COMPLETED:	01:35 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 11/22/23, Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced annual required visit using the Care Inspection Tool. LPA was first greeted by House Manager Corinthian Taporco then was joined with Administrator Jerissa Bucu and explained the purpose of today’s visit. The facility is licensed to operate for six (6) non-ambulatory of which one (1) may be bedridden of elderly residents ages 60 and above. The facility is approved for four (4) hospice residents. The facility is a single-story structure located in a residential neighborhood. It consists of the following: three (3) resident bedrooms, one (1) staff bedroom, two (2) resident bathrooms, one (1) staff bathroom, living area, dining area, kitchen, outside covered patio area. The washer and dryer are in the attached garage which is also used for storage. LPA and administrator 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 was 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 clean and operational. LPA observed all bathrooms to have secured handrails and non-skit mats or chairs for the shower. The water temperature measured 108.3 F in resident bathroom number one (1) and 109.8 F in resident bathroom number two (2). A comfortable temperature was maintained in the facility. LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for cleaning supplies, toxins, and sharp objects were stored, and inaccessible to residents. Continued on LIC 809-C

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Elvira Gonzalez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2023

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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SWEET LIFE COTTAGE	FACILITY NUMBER: 198320298
	VISIT DATE: 11/22/2023

NARRATIVE

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The kitchen was inspected and there is sufficient perishable and non-perishable food available, maintained properly. A fire extinguisher was charged, smoke detectors and carbon monoxide were operable. LPA observed the First aid kit and found it to fully stocked of the required items, with manual. LPA observed all medications are stored, secured and inaccessible to residents. LPA reviewed medications for five (5) residents and matched them to the MARs. LPA observed all medications to be in their original packaging. The facility has a working landline telephone and the last fire drill was conducted on 11/10/23.

During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff residents were wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The facility has an approved Mitigation Plan Report with CCLD.

No Deficiencies were cited during this inspection visit.

An exit interview was conducted and a copy of this report was provided to Administrator Jerissa Bucu.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Elvira Gonzalez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2023

LIC809 (FAS) - (06/04)

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