331880757-12-13-2023-18-AS-CNWE-CYGTUS-20231213140250

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331880757
Report Date: 12/13/2023
Date Signed: 12/13/2023 02:02:56 PM

Document Has Been Signed on 12/13/2023 02:02 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 BEST LIFE		FACILITY NUMBER:	331880757
ADMINISTRATOR:	THOMAS UATA		FACILITY TYPE:	740
ADDRESS:	33769 SALVIA LANE		TELEPHONE:	(951) 679-7454
CITY:	MURRIETA	STATE: CA	ZIP CODE:	92563
CAPACITY:	6	CENSUS: 5	DATE:	12/13/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Dawn Jensen, Caregiver		TIME COMPLETED:	02:10 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 12/13/2023, Licensing Program Analyst (LPA) Chinwe Nwogene arrived unannounced at the facility to conduct an annual inspection. LPA Nwogene was greeted and granted entry by Caregiver, Dawn Jensen who was informed of the purpose of the visit. LPA spoke to Administrator, Thomas Uata via telephone who was also informed of the purpose of the visit. At the time of visit there was three #3 staff and five #5 residents present. LPA toured the facility inside and out with Dawn Jensen.

Tour included:

Kitchen: LPA toured the kitchen and observed kitchen to be clean. Food is stored in a safe and healthful manner. Utensils and dishware are sufficient for the census. The refrigerator and stove are in working order. Sharps are stored in a locked kitchen drawer, available only to authorized individuals. Trash cans has tight-fitting lids. Fridge, freezer, and all need appliances were present and shown to be in working condition and clean.

Dining and Livingroom; LPA toured the dinning and Livingroom area. LPA observed area to be clean and furnitures in good condition. Temperature was 73 degrees Fahrenheit.

Hallway: LPA toured the hallway and observed hallway to be clean with no pathway obstruction. LPA inspected the fire extinguisher and found it to be in compliance and record to be up to date. Carbon monoxide & smoke detector were tested and functioning properly. LPA observed additional linens and hygiene items.

Medication: Medications were labeled and stored in separate bins inside of a locked medication closet and are distributed according to physician orders. The first aid kit was complete.

Continue on LIC809-C

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Chinwe Nwogene	TELEPHONE: (951) 202-2066
LICENSING EVALUATOR SIGNATURE:	DATE: 12/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 3

Document Has Been Signed on 12/13/2023 02:02 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 BEST LIFE	FACILITY NUMBER: 331880757
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(f)

Personnel Records

(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements: 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 by not having staff #1 and #2 documents and file available for LPA to review which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/22/2023
	Plan of Correction
1 2 3 4	Administrator stated copies of staff #1 and #2 documents and file will be emailed to LPA by the POC due date 12/22/2023.

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: Rikesha Stamps	TELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Chinwe Nwogene	TELEPHONE: (951) 202-2066
LICENSING EVALUATOR SIGNATURE:	DATE: 12/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

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 BEST LIFE	FACILITY NUMBER: 331880757
	VISIT DATE: 12/13/2023

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
26
27
28
29
30
31
32

Continued from LIC809.

Bathroom: LPA toured hallway bathroom and observed bathroom to be clean and equipped with grab bar and non-skid mat. There is also a good number of personal toiletries available for the residents in care. The hot water measured at 114 degrees Fahrenheit.

Bedroom: LPA toured four #4 out of #4 resident bedrooms and observed bedrooms to be clean and furnished according to regulation, which includes proper furniture, dressers, chairs, and lighting. Resident #1 bedroom has a private bathroom. LPA observed bathroom to be clean and hot water was measured at 114 degrees Fahrenheit.

Garage: LPA tour the garage and observed garage to be clean.

Laundry: Washing Machine and Dryer are all in good repair and sufficient for the census. Cleaning supplies are stored away in the laundry room, inaccessible to clients.

Backyard: LPA toured the backyard and observed backyard to be clean and furnitures in good condition. The backyard was free from obstruction and the side gate remain unlocked. No bodies of water were observed.

Food Services: There are seven days non-perishable and two days of perishable food supply present, and all food was properly stored and available to residents. Fridge and freezer are large enough to accommodate required perishable foods.

Records: All staff present were confirmed as being associated with the facility. LPA requested for three #3 staff and #3 residents' records. Three residents and two staff records were reviewed. One staff had no documentation of criminal record clearance, TB test, and Health screening. Administrator informed LPA that documents were completed but are not present at the facility. Administrator also informed LPA that the third staff has a file, but the file is not present at the facility (citation will be issued). All required postings were posted near the entryway and throughout the facility. The administrator certificate expires on 2/5/2025.

Interview: Three #3 staff and four #4 residents were interviewed.

Therefore, based on the observations made during today’s visit, one #1 deficiency will be cited per Title 22, Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted, and this reported was provided along with appeal rights to Dawn Jensen.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Chinwe Nwogene	TELEPHONE: (951) 202-2066
LICENSING EVALUATOR SIGNATURE:	DATE: 12/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3