198600082-2-8-2023-11-AS-WGIS-CN823B-20230118160204

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198600082
Report Date: 01/18/2023
Date Signed: 02/08/2023 05:08:36 PM

Document Has Been Signed on 02/08/2023 05:08 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	GOODLIFE HOME, THE		FACILITY NUMBER:	198600082
ADMINISTRATOR:	SHARRON BABB		FACILITY TYPE:	735
ADDRESS:	3837 W 134TH PL		TELEPHONE:	(310) 978-8021
CITY:	HAWTHORNE	STATE: CA	ZIP CODE:	90250
CAPACITY: 4		CENSUS: 3	DATE:	01/18/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Brenda Harrison		TIME COMPLETED:	03:45 PM

NARRATIVE

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Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced required annual visit with a primary focus on Infection Control measures using the CARE Inspection Tools. Upon arrival, LPA did a risk assessment at the door. Based on the assessment, the facility is clear of Covid-19 infection. LPA met with DSP, Brenda Harrison and explained the purpose of this visit. The facility is licensed for 4 bedridden developmentally disabled adults; there are currently three (3) clients in placement.

Structure The facility is a one-story home located in a residential neighborhood. The facility consisted of (4) client bedrooms, (3) bathrooms, living room, dining room, kitchen, and backyard patio area.

Physical Plant LPA toured the facility inside and out with Brenda. The front is landscaped and well maintained. The backyard is well maintained. It has chairs and a table available for residents. No bodies of water were observed. Walkways around the home were clear of hazards, obstructions, and debris. Gates open easily.

Bedrooms All bedrooms have the required furniture including bed, dresser, nightstand, and chair. All bedrooms have ample lighting and closet space. The beds have the required linens including mattress pad, fitted sheets, blanket, comforter and pillow. Facility rooms are clean and in good repair.

Bathroom LPA inspected the resident bathrooms and found them well maintained. The toilet and faucet are in good working condition. The shower is clean and free of mildew and mold. The shower has a shower chair and secured safety rails. There was sufficient liquid soap and paper towels observed. Water temperature measured at 115.4 degrees Fahrenheit.

Linens and Hygiene LPA observed an ample supply of sheets and towels in a closet in the hallway. Residents have their toiletries stored in a catty in their closets. Additional supplies are stored in a cabinet in the kitchen service area.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2023

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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: GOODLIFE HOME, THE	FACILITY NUMBER: 198600082
	VISIT DATE: 01/18/2023

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Kitchen The kitchen was clean and well maintained. All appliances were in good working order. All cutleries were in good condition. LPA observed a 3-day supply of perishable foods and a 7-day supply of nonperishable foods. Sharps were locked in a drawer in the kitchen. Toxins were locked and stored in a cabinet in the service are. Water temperature measured 118.1-degrees Fahrenheit.

Common Rooms Dining room had a large table and ample seating to accommodate all residents. The living room had ample seating for all residents. LPA observed games and activities for residents. A comfortable temperature was maintained in the facility. All walkways were clear of hazards and obstructions.

Safety The facility has 5 smoke/carbon monoxide detectors. There is a fully charged fire extinguisher mounted in the hallway that was last services on October 12, 2022. The last emergency drill was on November 1, 2022. All exits are clearly marked. All necessary posting are displayed. LPA observed the First Aid Kit to have all the necessary item and the manual. There is a working landline.

Infection Control Upon arrival LPA was screened for Covid. During the tour, LPA observed the facility’s infection control practices. LPA observed a sanitizing station at the facility entrance; visitors log with Covid-19 screening and temperature log, and records of daily Covid-19 screening and temperature checks of residents and staff. PPE supplies are readily available to staff. Sufficient paper, cleaning, and disinfecting supplies were observed. Staff were wearing face covering. LPA observed required postings throughout the facility.

Files LPA reviewed all 3 resident files and found they contained all the necessary documentation. LPA reviewed all 4 staff files and found they contained all the required documentation and training.

Medications LPA reviewed all resident medications and matched them to the MARs. All medications are stored and locked in a cabinet in the kitchen service area.

Advisory Notes:

1. Change light bulb in the hallway outside residents bedrooms and bathroom.

No deficiencies were cited during this visit. An exit interview was conducted, and a copy of this report submitted to Brenda Harrison.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2023

LIC809 (FAS) - (06/04)

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