<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881278
Report Date: 06/02/2022
Date Signed: 06/02/2022 12:32:18 PM


Document Has Been Signed on 06/02/2022 12:32 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:NEW LIFE SENIORS GUEST HOMEFACILITY NUMBER:
361881278
ADMINISTRATOR:MANGANGEY, GLORY ANNEFACILITY TYPE:
740
ADDRESS:13560 COBALT ROADTELEPHONE:
(760) 995-7832
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY:6CENSUS: 5DATE:
06/02/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Administrator/Applicant Glory Anne MangangeyTIME COMPLETED:
12:45 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
Licensing Program Analyst (LPA) Melody Brown conducted an announced visit to the facility 06/02/2022 for purpose of a Change of Ownership evaluation. At approximately 10:20 AM, LPA met with Administrator/Applicant Glory Anne Mangangey. An initial application for change of ownership to operate a Residential Care for the Elderly (RCFE) was submitted to the Central Applications Bureau (CAB) on 10/10/2021 for a total capacity of six (6) non-ambulatory residents. Fire clearance was granted on 03/24/2022 for six (6) non-ambulatory residents. LPA Brown observed the following:
Structure:
Facility was a one-story house with four (4) resident bedrooms, three (3)resident/staff bathrooms, living room, dining area and kitchen. There was an attached two (2) car garage in the left side of the house.
Heating/Cooling System:
Central heating and air conditioning system installed with a central panel located in the hallway to control the entire house.
Bedrooms:
Each resident bedrooms accommodate any non-ambulatory resident. All resident bedrooms were adequately furnished with bed, chair, closet, appropriate linens, adequate lighting, and an operable smoke alarm.
Bathrooms:
The three (3) resident/staff bathrooms have a working toilet, wash basin, and shower with an adequate supply of toilet paper and soap. At 11:15 AM, LPA tested the water temperatures in the resident bathroom. LPA verified water temperature was measured at 113 degrees Fahrenheit.

***CONTINUED ON LIC 809-C***

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2022
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


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: NEW LIFE SENIORS GUEST HOME
FACILITY NUMBER: 361881278
VISIT DATE: 06/02/2022
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 LIC 809***

Kitchen/Laundry:
An adequate supply of dishes, glasses, utensils, pots, and pans were observed. Knives/sharp instruments were secured in a locked drawer located in the kitchen. There was adequate room for food storage. LPA observed the stove to be operational. Refrigerator/freezer were in working condition. There is sufficient storage for perishable food. There was adequate seating for meals for all residents. Laundry room with washer and dryer was in the hallway. Laundry detergents and cleaning supplies were observed in the garage, garage door is locked away from residents.

Living/Family room:
There was a living/family room with adequate seating for all residents and a working TV.

Linens and Hygiene Supplies:
An adequate supply of linens was stored in a cabinet in the main hallway of the residence.

Yards/Outside:
Patio furniture for outdoor seating observed. Self-latching handle on right side of the house that leads into the backyard. All outdoor pathways were free of obstructions.

Emergency Phone Numbers, and Exit Plan:
Facility sketch were observed posted in the hallway leading to the residents bedroom. There were Ombudsman poster, and Let-Us-No poster observed. with Emergency Disaster Plan posted.

General items:
One (1) fire extinguisher were charged and located in the hallway leading to the residents’ bedrooms, six (6) smoke alarms and two (2) carbon monoxide detectors were tested and were observed to be in working order. Resident records were stored in a locked cabinet in the hallway. First Aid kit with required components, and locked area for medication storage was observed. LPA observed a facility phone and was operational as evidenced by LPA dialing the number. The phone number designated for the facility is 760-493-1582. There is enough Emergency water supply observed and the required 72-hour emergency food supply was discernible from the regular food supply. Component III was completed on this day as well.
***CONTINUED ON LIC 809-C***
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2022
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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: NEW LIFE SENIORS GUEST HOME
FACILITY NUMBER: 361881278
VISIT DATE: 06/02/2022
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 LIC 809***

Additionally, LPA Brown observed facility to have required single entry point for COVID screening, upon entering facility. LPA Brown observed required COVID signages throughout the facility, Visitation Vaccination Requirement and soap and paper towels in bathrooms for washing hands. LPA observed activities for the residents such as books and games.

The facility was evaluated in accordance with the California Code of Regulation (CCR), Title 22, Division 6, Chapters 1 and 6 to ensure the health and safety of residents in care. Facility appears to be ready for licensure.

An exit interview was conducted, and a copy of this report was reviewed and provided to Administrator/Applicant Glory Anne Mangangey.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3