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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600082
Report Date: 12/03/2021
Date Signed: 12/03/2021 02:53:59 PM

Document Has Been Signed on 12/03/2021 02:53 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
MONTERY PARK, CA 91754
FACILITY NAME:GOODLIFE HOME, THEFACILITY NUMBER:
198600082
ADMINISTRATOR:SHARRON BABBFACILITY TYPE:
735
ADDRESS:3837 W 134TH PLTELEPHONE:
(310) 978-8021
CITY:HAWTHORNESTATE: CAZIP CODE:
90250
CAPACITY: 4CENSUS: 2DATE:
12/03/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Sharron BabbTIME COMPLETED:
02:10 PM
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Licensing Program Analyst (LPA) Jeyde Cardenas conducted a Case Management visit in relation to the death of client #1. Death report received on 11/29/21. LPA met with Administrator, Sharron Babb and discussed the purpose of the visit. LPA conducted risk assessment to ensure facility is clear of covid-19 infection, facility was deemed clear of Covid-19.

During today's visit, LPA interviewed Administrator and staff present at the time of visit, LPA attempted to interview client#2 and client#3, and toured the physical plant. LPA was informed that on 11/25/21 client #1 was found in bed unresponsive and emergency response was contacted. Staff #1 administered CPR until the Paramedics arrived. Emergency response attempted to revive Client #1, however client was pronounced deceased at the facility.

On 12/2/21 LPA Cardenas was provided with copies of the following documents via email.
· IPP
· Physician's Report
· CDER
· Most recent medical Appointment records
· Medication Administration Record
· Annual behavior assessment dated: 01/22/21

LPA requested the Administrator, provide a copy of the death certificate when it becomes available.

Exit interview held and a copy of report provided to Sharron Babb.
SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Jey Cardenas
LICENSING EVALUATOR SIGNATURE: DATE: 12/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/03/2021
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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