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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006215
Report Date: 10/21/2022
Date Signed: 10/21/2022 11:07:16 AM

Document Has Been Signed on 10/21/2022 11:07 AM - 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:SWEET LIFE FAMILY HOME CAREFACILITY NUMBER:
306006215
ADMINISTRATOR:ANAYA, NORAFACILITY TYPE:
735
ADDRESS:38 GOLDEN STARTELEPHONE:
(949) 235-4752
CITY:IRVINESTATE: CAZIP CODE:
92604
CAPACITY: 4CENSUS: 4DATE:
10/21/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Laini Poling- Licensee TIME COMPLETED:
11:20 AM
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Licensing Program Analyst (LPA) Andrea Mendivil and Licensing Program Manager (LPM) Alisa Ortiz made an announced visit to conduct a pre-licensing inspection. LPA and LPM identified themselves and discussed the purpose of the visit with Licensee Laini Poling. An initial application to operate an Adult Residential Facility was received by CCL on 07/28/2022 for a capacity of four ambulatory clients. Facility has a screening area in the entrance of the facility. LPA and LPM observed covid signage at entrance to facility as well as around the residence. LPA and LPM observed a 4 week supply of PPE.
LPA Mendivil and LPM Ortiz along with Licensee toured the facility at 9:20 AM and observed the following:
Structure: Facility is a two-story, 6 bedroom, 3 bathroom house with an attached garage and a tan exterior. The exit gate is unlocked and self latching. Living Room/ Dining Room: Adequate seating is available in the dining room and living room. Bedrooms Residents: Rooms are double occupancy for clients. All of the rooms are equipped with appropriate lighting, chair, night stand and ample closet space. Upstairs contains 2 bedrooms and 1 bathroom and are for facility staff. Bathrooms: All resident bathrooms have a working toilet/ wash basin. Facility has sanitizer and paper towels in the restrooms.Linens & Hygiene Supplies: Facility has bedding and towels for clients in care. Emergency Phone Numbers and Exit Plan: Posted in entrance of facility. Food Service: Licensee has 2 day perishable and 7-day nonperishable foods. Smoke Detectors: Smoke detectors/ carbon monoxide detectors were tested and operational. Fire extinguisher present in entry of facility. Appliances: Stove, oven, refrigerator, microwave, washer, and dryer are clean and operational. Toxins/ Sharps: LPA and LPM observed a secure area for sharps or toxins. Water Temperature: LPA tested hot water and it read as following: bathroom downstairs reads at 113 degrees, master bathroom 115 degrees, upstairs bathroom sink #1 reads at 115 degrees sink #2 reads at 113 degrees. Emergency Supplies: LPA observed supply of emergency water and food. Medications, First-Aid Kit & Book: First aid kit observed contained all required items. CONTINUED ON LIC 809C DATED 10/21/2022
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2022
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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: SWEET LIFE FAMILY HOME CARE
FACILITY NUMBER: 306006215
VISIT DATE: 10/21/2022
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Medication is stored in a locked box in a kitchen cabinet. Facility to use a medication administration record. Resident & Staff File: Records are stored in a locked cabinet.. Reading Material, Games, and Equipment: Licensee has an activity schedule on the fridge. LPA observed games and books in facility. Backyard: LPA observed 4 chairs for outdoor seating. Fire Clearance: Approved for four ambulatory on 08/09/2022.

Facility is ready to be licensed. Component III completed. Exit interview conducted and a copy of this report was left at the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022
LIC809 (FAS) - (06/04)
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