331880755-10-24-2023-18-AS-CGOH-CWWPEM-20231024111521

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331880755
Report Date: 10/24/2023
Date Signed: 10/24/2023 11:15:25 AM

Document Has Been Signed on 10/24/2023 11:15 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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	SARAH'S GOOD LIFE		FACILITY NUMBER:	331880755
ADMINISTRATOR:	UATA, THOMAS		FACILITY TYPE:	740
ADDRESS:	26171 FOUNTAIN BLEU DRIVE		TELEPHONE:	(951) 679-7454
CITY:	SUN CITY	STATE: CA	ZIP CODE:	92586
CAPACITY:	6	CENSUS: 3	DATE:	10/24/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Caregiver, Cassandra Geurkink		TIME COMPLETED:	11:15 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Cheryl Goodrich arrived at 9:35am to the facility to complete the unannounced required - 1 year annual inspection. LPA met with Caregiver, Casandra Geurkink at the front door and was granted entry. The purpose of today's visit is to inspect the facility to ensure that the facility is in compliance with California Code of Regulations, Title 22, Division 6. The facility is approved for 6 non-ambulatory residents with 3 residents in care. The facility has an approved hospice waiver for 4 residents. Infection Control: The facility has an approved infection control plan and a surplus of infection control supplies including but not limited to gloves, masks, gown and cleaning supplies. Operational Requirements: The facility has a plan of operation, an approved infection control plan, and has an approved fire clearance and liability insurance. Physical Plant & Environmental Safety: The facility is a one story home located in residential Sun City, CA. The facility temperature read at 72 degrees. The facility has 3 bedrooms, and 2 bathrooms, living room, kitchen, dining room and backyard. The bedrooms have beds with clean linen, dresser, TV and closet space. The bedrooms are clean and clear of obstruction. The bathroom temperature read at 114 degrees which is within regulation requirements. The kitchen, living room and dining room are all clean and clear of obstruction. The medications are kept in the hallway near the front door and inaccessible to residents in care. The facility has no bodies of water on the premises. Staffing: The facility has one staff member on site to care for the 3 residents in care during the day and one staff member on site during the night. The facility has adequate supervision of the residents in care. Personnel and Training Records: The staff have complete training records containing; applications, Fingerprint clearance, Health and TB screening, and in-service trainings. (Continued on LIC809-C)

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Cheryl Goodrich	TELEPHONE: 951-248-0308
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023

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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: SARAH'S GOOD LIFE	FACILITY NUMBER: 331880755
	VISIT DATE: 10/24/2023

NARRATIVE

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(Continued from LIC809)

Residents Right Information: The facility has posted resident's right information.
Planned Activities: The facility has planned activities for each resident based on their mobility and level of comfort.
Food Service: A 7-day non-perishable and 2-day perishable food supply was observed and all food was properly stored and available to residents in care.
Incidental Medical and Dental: The facility has the resident's medication properly stored in the hallway near the door. The facility documents the distribution of medication in the medication logbook. The facility is in compliance with physician's orders and regulations.
Disaster Preparedness: The facility has an Emergency Disaster Plan with evacuation routes posted for both staff and residents in care. The facility has posted the Emergency phone numbers list. The facility has smoke and carbon monoxide detectors and fire extinguishers that are in working order.
Residents with Special Needs: The facility has an approved Hospice Waiver for 4. The facility continues on-going training for residents with special needs and documents the training.
Summary: Based on today's visit, no deficiencies were observed at this time. An exit interview was conducted with Caregiver, Casandra Geurkink and a copy of this report was printed, signature below confirms the receipt of these rights.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Cheryl Goodrich	TELEPHONE: 951-248-0308
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023

LIC809 (FAS) - (06/04)

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