198600082-6-12-2024-11-AS-FSHY-D66UQ7-20240612154642

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198600082
Report Date: 06/12/2024
Date Signed: 06/12/2024 03:46:49 PM

Document Has Been Signed on 06/12/2024 03:46 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME:	GOODLIFE HOME, THE		FACILITY NUMBER:	198600082
ADMINISTRATOR/ DIRECTOR:	SHARRON BABB		FACILITY TYPE:	735
ADDRESS:	3837 W 134TH PL		TELEPHONE:	(310) 978-8021
CITY:	HAWTHORNE	STATE: CA	ZIP CODE:	90250
CAPACITY: 4		CENSUS: 4	DATE:	06/12/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:30 AM
MET WITH:	Brenda Harrison, Administrator		TIME VISIT/ INSPECTION COMPLETED:	03:45 PM

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On 6/12/24, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced required annual visit using the full CAREs Inspection Tool. LPA met with Administrator, Brenda Harrison and explained the purpose of today’s visit. The facility is licensed to serve elderly developmentally disabled residents ages 18 – 59 years old.

LPA reviewed all resident files and found they contained the required documents. LPA reviewed five (5) staff files and found they contained the required documents, training, and certification. LPA reviewed the surety bond.

LPA Felisa and Brenda toured both inside and outside of the facility. The facility is a one-story structure located in a residential neighborhood. The facility consists of (4) client bedrooms, (2) bathroom, (1) staff bathroom, living room, kitchen, dining area, patio, garage used for storage and laundry area. Facility maintains all required posting throughout the facility.

All bedrooms were toured. Bedrooms 1-4 are occupied by residents and contain the mandated furniture. LPA observed all rooms to have the required furniture including a bed, dresser(s), nightstand, and chair(s). All beds had the required linens including a mattress cover, fitted sheets, blanket, comforter, and pillow. LPA observed ample lighting in all the bedrooms.

LPA Shirley and Brenda toured the kitchen and found it to be clean and sanitary. All appliances were in good working order. Knives were locked and stored. The medications were locked and stored in a cabinet in the hallway and inaccessible to the resident. LPA observed a 3-day supply of perishable and a 7-day supply of nonperishable foods. The water temperature measured 113.9 degrees Fahrenheit.

Con'd 809-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 06/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024

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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: GOODLIFE HOME, THE	FACILITY NUMBER: 198600082
	VISIT DATE: 06/12/2024

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The (2) bathrooms have grab bars and are clean and operational. First aid kit is fully stocked with manual. No firearms are stored at facility and no bodies of water present. This facility is in good repair.

LPA Shirley and Brenda walked through all common areas. In the living room, kitchen, dining room there is ample seating and space for all residents. All rooms and walkways were clean, and clear of obstructions and hazards. All areas have ample lighting. All rooms, hallway, and living room have working smoke detectors. There is a charged fire extinguisher in the hallway near the backdoor and in the hallway by bedrooms #2 and #3. The backyard is clean and clear of obstructions and hazards, shaded area and there are no bodies of water present.

LPA conducted a records review of (4) client records, (5) staff records and reviewed the facility disaster plan. The facility disaster plan was current and in compliance with Title 22 at the time of visit. LPA reviewed clients medications and Medication Administration Records (MAR).

LPA did not observe any discrepancies at the time of visit.

An exit interview was conducted, and a copy of this report was provided to Administrator, Brenda Harrison.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 06/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024

LIC809 (FAS) - (06/04)

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