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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803606
Report Date: 07/23/2021
Date Signed: 07/23/2021 03:34:04 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:LONG LIFE LIVING INC IIFACILITY NUMBER:
216803606
ADMINISTRATOR:CHANG, FAYEFACILITY TYPE:
740
ADDRESS:15 PIKES PEAK DRIVETELEPHONE:
(415) 472-5876
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY:6CENSUS: 6DATE:
07/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Care Giver, Yacin Ovilla
Administrator, Faye Chang		TIME COMPLETED:
10:30 AM
NARRATIVE
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Long Life Living II for the purpose of conducting a Required 1-year inspection. LPA met with Care Giver, Yacin Ovilla, and was granted access into the facility. Administrator, Faye Chang arrived 30 minutes later.

LPA toured the facility with Care Giver, Yacin Ovilla. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Exits were equipped with auditory devices; Fire Extinguisher was found to be last charged on June 2019 (Photo taken- See LIC 809D). Smoke detectors and carbon monoxide detectors were found to be operational during the visit. Hot water temperature measured within Title 22 acceptable regulation of 105 to 120 degrees F. The facility serves residents with dementia and has a plan of operation for special care and programming. There was a sufficient supply of both perishable and nonperishable food as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored in a garage, locked and inaccessible to residents in care. There was a supply of cleaners, hygiene products and paper products available for residents. The bathrooms designated for residents at the facility were supplied with paper towels and hand soap dispensers. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom shower. All bedrooms have lighting & appropriate furnishings. Resident’s beds were outfitted with mattress pads as required by Title 22 Regulations. LPA observed a baby monitor in residents bedroom closest to the kitchen (Photo taken-See LIC 809-D).

LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Facility has PPE supply located in the staff room. Staff have had all PPE training required on file. Facility staff is N95 Fit tested.

Deficiencies were observed on July 23, 2021 during a facility tour, and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. A copy of this report was and given to the Administrator, Faye Chang. Appeal rights were given.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: LONG LIFE LIVING INC II
FACILITY NUMBER: 216803606
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/23/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468.2(a)(1)
87468.2 (a)(1) Additional Personal Rights of Residents in Privately Operated Facilities- (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:

(1) To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone conversations, use of the Internet, and meetings of resident and family groups.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above in 1 out of 6 residents in care had a baby monitor installed in the bedroom of which the resident resides in. This does not allow for privacy and/or not a substituition for staff monitoring of a resident. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/30/2021
Plan of Correction
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LPA educated staff on Personal Rights and privacy. Facility took out the baby monitor right away. LPA recommended retraining on staff regarding Personal Rights.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:
DATE: 07/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: LONG LIFE LIVING INC II
FACILITY NUMBER: 216803606
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/23/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87203
87203 Fire Safety. All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, licensee did not comply with the section cited above in 2 out 2 fire extingushers were last inspected in June 2019. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/30/2021
Plan of Correction
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LPA educated facility on the importance of obtaining an annual inspection of the fire extinguisher. Facility will have the fire extinguisher inspected by next week.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:
DATE: 07/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3