331880755-10-3-2024-18-AS-JGEE-D9PSB9-20241003134333

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331880755
Report Date: 10/03/2024
Date Signed: 10/03/2024 01:43:39 PM

Document Has Been Signed on 10/03/2024 01:43 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
RIVERSIDE ASC, 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: 5	DATE:	10/03/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Senior Manager Brandee Geurkink		TIME COMPLETED:	01:50 PM

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	On 10/03/24 Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to conduct a 1 year required visit. LPA was greeted ad granted entry by Caregiver Casandra Geurkink, where LPA explained the purpose of the visit. At the time of the visit there was (1) staff and (5) residents present. The facility licensed to serve (6) non ambulatory residents age range 60 and over. The facility also has an approved hospice waiver for (4), there is currently (0) residents receiving hospice care, and (1) receiving home health services. Senior Manager Brandee Geurkink arrived shortly after and accompanied LPA on a tour of the facility. The home is a single story structure consisting of 4 bedrooms and 2 bathrooms, garage, backyard, kitchen, living room and den. The facility was observed to be clean, with the passageways being from of any obstructions. The medications were observed to be locked and inaccessible to residents in care. The facility is using an electronic Medication Authorization Record (MAR) program. The facility food supply was observed to be sufficient as there was a 2 day supply of perishable and a 7 day supply of perishable food items. The facility was observed to have 2 fully charged fire extinguishers that were last services on 09/18/24. The facility does not have any pools or bodies of water on the premises, or no known guns or ammunition. The hot water was tested and found to be within regulatory limits measuring at 112.2 degrees Fahrenheit. There was no log available for LPA to review verify whether the facility is conducting emergency disaster drills on a quarterly basis as required. Deficiency cited. LPA conducted a review of both resident and staff files. The resident files were observed to have the required documentation such as physician's reports, and appraisals. All staff present were observed to have obtained criminal record clearance and to be associated to the facility. In addition to having valid CPR certification, The administrator Thomas Uata was observed to have a valid certificate that expires on 2/25/25.

SUPERVISOR'S NAME: Tricia Danielson	TELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 217-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024

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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Document Has Been Signed on 10/03/2024 01:43 PM - 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
RIVERSIDE ASC, 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: 10/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 1 out of 1 times which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/04/2024
	Plan of Correction
1 2 3 4	The Licensee agrees to conduct and log an emergency disaster drill. Proof of POC is to be submitted to the department by 5pm on the due date indicated.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Tricia Danielson	TELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 217-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024

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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: SARAH'S GOOD LIFE	FACILITY NUMBER: 331880755
	VISIT DATE: 10/03/2024

NARRATIVE

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During today's visit LPA reminded about the facility annual fees that are due on or before 10/29/24, and provided the following pin 600382. It was also shared that the facility will be having the roof replaced, there are not currently any leaks, the roof is just in in need of an overall upgrade.

Based on today's inspection a citation will be issued in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 8) on the attached 809D.

An exit interview was conducted and a copy of this report, appeal rights, Li 9098-Proof of corrections form was provided to Senior Manager Brandee Geurkink.

SUPERVISOR'S NAME: Tricia Danielson	TELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 217-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024

LIC809 (FAS) - (06/04)

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