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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005209
Report Date: 07/15/2022
Date Signed: 07/15/2022 04:23:17 PM


Document Has Been Signed on 07/15/2022 04:23 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:BEST LIFE HOME CARE, LLC.FACILITY NUMBER:
347005209
ADMINISTRATOR:BUTTS, CHRISFACILITY TYPE:
740
ADDRESS:7205 BARANGA DRIVETELEPHONE:
(916) 726-2292
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95621
CAPACITY:6CENSUS: 5DATE:
07/15/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Chris Butts, AdministratorTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Michael Hood met with Administrator, Chris Butts, to conduct a case management visit.

During inspection conducted on 10/28/2021, LPA requested all incident reports regarding resident (R1). LPA obtained what Unusual Incident Reports (SIRs) the Administrator supplied.

On 5/18/2022, the Department received 2 SIRs regarding R1 dated 9/8/2021 and 9/29/2021. Due to facility not supplying the Department with all requested documents during inspection conducted on 10/28/2021, a deficiency is being cited pursuant to California Code of Regulations, Title 22, Section 87506(a) regarding complete resident records. Deficiencies are listed on 809-D.

Exit interview was conducted with Administrator. A copy of this report and appeal rights were provided. The Administrator’s signature on these forms acknowledges receipt of these documents.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: 916-531-7341
LICENSING EVALUATOR SIGNATURE:
DATE: 07/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/15/2022
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 07/15/2022 04:23 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926


FACILITY NAME: BEST LIFE HOME CARE, LLC.
FACILITY NUMBER: 347005209

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/29/2022
Section Cited

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87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidence by:
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Based on oberservation made by LPA during prior inspection, facility did not ensure that all documents requested by the department were received when requested, which poses an potential health, safety, and personal rights risk to the residents in care.
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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: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: 916-531-7341
LICENSING EVALUATOR SIGNATURE:
DATE: 07/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/15/2022
LIC809 (FAS) - (06/04)
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