331880756-11-15-2024-56-AS-MBRN-DB2SQ3-20241115130405

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331880756
Report Date: 11/15/2024
Date Signed: 11/15/2024 01:04:17 PM

Document Has Been Signed on 11/15/2024 01:04 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME:	SARAH'S GREAT LIFE		FACILITY NUMBER:	331880756
ADMINISTRATOR/ DIRECTOR:	UATA, THOMAS		FACILITY TYPE:	740
ADDRESS:	35725 VERDE VISTA WAY		TELEPHONE:	(951) 691-8152
CITY:	WILDOMAR	STATE: CA	ZIP CODE:	92595
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	11/15/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:45 AM
MET WITH:	Facility Manager Brandee Geurkink		TIME VISIT/ INSPECTION COMPLETED:	01:05 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 11/15/2024 at 08:45 AM, Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA Brown met with a staff and was granted entry to the facility. At the time of the visit there were two (2) staff present, and five (5) residents present. Licensee/Administrator Thomas Uata was contacted and informed of the visit. Staff #3 (S3) informed Facility Manager Brandee Geurkink of the visit. LPA Brown explained the purpose of the visit to Facility Manager Brandee Geurkink. The facility is a Residential Care Facility for the Elderly (RCFE). The facility is a four (4) bedroom, three (3) bathroom home with a kitchen/dining area, two (2) living room areas, laundry room and an attached two-car garage. The facility is licensed for a capacity of six (6) non-ambulatory residents. The current census is five (5) residents. LPA Brown was accompanied by Facility Manager Geurkink to conduct a general overall inspection, which included, but was not limited to, the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). There are no obstructions to interior and exterior passageways. The facility is maintained at a comfortable temperature of 75 degrees Fahrenheit. LPA Brown inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, and storage space. However, LPA Brown observed insufficient lighting on resident bedrooms to ensure the comfort and safety of residents at the facility. Deficiency will be issued. Also, LPA Brown observed no chairs provided on resident bedrooms. Technical Violation will be issued. Moreover, LPA Brown observed that bathrooms were clean, and appliances were operating appropriately. LPA Brown observed sufficient furniture throughout the facility. LPA Brown measured and observed the water temperature in the residents shared bathroom to be at 106.8 degrees Fahrenheit. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Postings such as the facility license, personal rights, the CCLD complaint poster, ombudsman poster, labor laws, and the disaster plan were posted in a common area. *Continuation in LIC809C*

Efren Malagon	TELEPHONE: (951) 202-6356
Melody Brown	TELEPHONE: 951-897-2187
	DATE: 11/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024

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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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
, CA 92507

FACILITY NAME: SARAH'S GREAT LIFE	FACILITY NUMBER: 331880756
	VISIT DATE: 11/15/2024

NARRATIVE

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Cleaning supplies were kept inaccessible to residents in care, however, LPA Brown observed one (1) sharp scissor and two (2) sharp peelers in the kitchen drawer, not locked and accessible to residents in care. Deficiency will be issued. To add to that, LPA Brown did not observe night lights maintained in hallways and passages to non-private bathrooms. Deficiency will be issued. During the tour of the facility, LPA Brown observed that the facility does not have the required emergency supplies, emergency food and emergency water. Deficiency will be issued. There was a designated storage space for resident/staff files. Medications are kept in the medication room. LPA Brown observed he facility is clean and in good repair for residents in care.

Food Service: Seven (7) days non-perishable and two (2) days perishable food supply observed at the facility.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. Also, LPA Brown noted that there's a staff scheduled to work the night shift as required for facility with dementia residents.

Record Review: LPA Brown observed Infection Control Plan, dementia care plan and the required updated liability insurance maintained at the facility. Also, LPA Brown reviewed three (3) resident files for admission agreements, updated physician reports, pre-placement appraisals, needs and services plans and centrally stored medication list. LPA Brown observed missing Resident/Responsible Party Signature and Signature Date and Licensee or LIcensee's designated Representative Signature and Signature date in Resident #3 (R3) Admission Agreement. Deficiency will be issued. Also, LPA Brown observed that Resident #3 (R3) does not have R3's signature/Responsible Person signature and signature date and Resident #2 (R2) Pre-Admission Appraisal does not have R2's Responsible Person signature date. Deficiency will be issued. LPA reviewed three (3) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test results. LPA Brown noted that the files reviewed were complete.

Medications/Medication Administration Records (MARs) were audited for three (3) residents and appeared to be dispensed and logged appropriately.

Based on the observations made during today’s visit, deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809), LIC809D and Appeal Rights were discussed and provided to Facility Manager Brandee Geurkink.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/15/2024 01:04 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: SARAH'S GREAT LIFE	FACILITY NUMBER: 331880756
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that the one (1) sharp scissor and two (2) sharp peelers in the kitchen drawer were locked and not accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/16/2024
	Plan of Correction
1 2 3 4	Licensee stated to train all staff on CCR 87705(f)(1) and submit proof to LPA Brown on Plan of Coorection (POC) due date.

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.

Efren Malagon	TELEPHONE: (951) 202-6356
Melody Brown	TELEPHONE: 951-897-2187
	DATE: 11/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/15/2024 01:04 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: SARAH'S GREAT LIFE	FACILITY NUMBER: 331880756
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Maintenance and Operation

(d) There shall be lamps or light appropriate for the use of each room and sufficient to ensure the comfort and safety of all persons in the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that there are sufficient light on resident bedrooms to ensure the comfort and safety of residents which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/22/2024
	Plan of Correction
1 2 3 4	Licensee stated to provide additional lightning on resident bedrooms to ensure the comfort and safety of residents and submit proof to LPA Brown on Plan of Correction (POC) due date.

Section Cited

Personal Accommodations and Services

(5) Night lights shall be maintained in hallways and passages to nonprivate bathrooms. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that night lights are maintained in hallways and passages to non-private bathrooms which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/22/2024
	Plan of Correction
1 2 3 4	Licensee stated to obtain/purchase night lights and install on hallways and passages to non-private bathrooms and submit proof to LPA Brown on POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Efren Malagon	TELEPHONE: (951) 202-6356
Melody Brown	TELEPHONE: 951-897-2187
	DATE: 11/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/15/2024 01:04 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: SARAH'S GREAT LIFE	FACILITY NUMBER: 331880756
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Evaluation of Suitability for Admission

(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that the Pre-Admission Appraisal of Resident #3 (R3) have have R3's signature/Responsible Person signature and signature date and Resident #2 (R2) Pre-Admission Appraisal has R2's Responsible Person signature date which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/22/2024
	Plan of Correction
1 2 3 4	Licensee stated toi submit completed copies of R3 and R2 Pre-Admission Appraisal to LPA Brown on Plan of Correction (POC) due date.

Section Cited

Admission Agreements

(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that Resident #3 (R3) Admission Agreement was complete as evidenced of missing R3 Reponsible Party Signature and Signature Date and Licensee or LIcensee's designated Representative Signature and Signature date observed which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/22/2024
	Plan of Correction
1 2 3 4	Licensee stated to train all staff on CCR 87507(c) and submit proof of staff training log to LPA Brown on POC due date. Also, Licensee stated to submit a completed copy of R3 Admission Agreement with the required signature and signature date of R3 Representative and Licensee or LIcensee's designated Representative to LPA Brown on POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Efren Malagon	TELEPHONE: (951) 202-6356
Melody Brown	TELEPHONE: 951-897-2187
	DATE: 11/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024

LIC809 (FAS) - (06/04)

Page: 5 of 7

Document Has Been Signed on 11/15/2024 01:04 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: SARAH'S GREAT LIFE	FACILITY NUMBER: 331880756
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Other Provisions

(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that the facility has the required emergency supplies, food and water which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/22/2024
	Plan of Correction
1 2 3 4	Licensee stated to obtain and prepare the required emergency supplies, food and water and submit proof to LPA Brown on Plan of Correction (POC) due date.

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.

Efren Malagon	TELEPHONE: (951) 202-6356
Melody Brown	TELEPHONE: 951-897-2187
	DATE: 11/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024

LIC809 (FAS) - (06/04)

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