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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880755
Report Date: 08/04/2022
Date Signed: 08/04/2022 11:09:19 AM


Document Has Been Signed on 08/04/2022 11:09 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:SARAH'S GOOD LIFEFACILITY NUMBER:
331880755
ADMINISTRATOR:UATA, THOMASFACILITY TYPE:
740
ADDRESS:26171 FOUNTAIN BLEU DRIVETELEPHONE:
(951) 679-7454
CITY:SUN CITYSTATE: CAZIP CODE:
92586
CAPACITY:6CENSUS: 4DATE:
08/04/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:21 AM
MET WITH:Thomas Uata, AdministratorTIME COMPLETED:
11:10 AM
NARRATIVE
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Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility to address concerns observed during the investigation of complaint #18-AS-20220729163748. The LPA met with Administrator, Thomas Uata, and informed him of the purpose of the visit.

During the visit the LPA observed the following concerns: Uata was not able to locate the files for the residents in care, and required the assistance of Staff One (S1) to locate the files; the file for Resident Four (R4) could not be found and could not be reviewed by the LPA; a review of R1's Physician's Report for Residential Care Facilities for the Elderly (RCFE) revealed a resident, who requires an annual medical assessment, was last evaluated on August 25, 2020; no copy of the staff schedule was available for review; per Uata, no Absentee Notification Plan (AB 620) was established following discussion of the plan with LPA, Jesse Gardner.

Administrator Uata has shown he is not operating the facility in compliance with regulatory requirements. Therefore, a citation will be issued.

An exit interview was conducted; this report was reviewed with Uata and a copy was provided, along with LIC 811 and Appeal Rights.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2022
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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Document Has Been Signed on 08/04/2022 11:09 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: SARAH'S GOOD LIFE
FACILITY NUMBER: 331880755

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/11/2022
Section Cited

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ADMINISTRATOR - QUALIFICATIONS AND DUTIES:...The administrator shall have sufficient freedom from other responsibilities & shall be on the premises a sufficient # of hours to permit adequate attention to the management & administration of the facility...The Department may require...the
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admin. devote additional hours in the facility to fulfill his responsibilities when the need for such additional hours is substantiated...This requirement wasn't met, as evidenced by: Based on observation, file review & interview, Admin. Uata has shown he is not operating the facility in compliance w/ requirements.
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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: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2022
LIC809 (FAS) - (06/04)
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