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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604665
Report Date: 04/17/2025
Date Signed: 04/17/2025 04:12:40 PM

Document Has Been Signed on 04/17/2025 04:12 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:MY BEST LIFE RESIDENTIALFACILITY NUMBER:
374604665
ADMINISTRATOR/
DIRECTOR:		GONZALEZ JR, EDUARDOFACILITY TYPE:
735
ADDRESS:1672 POINT REYES CTTELEPHONE:
(619) 990-8870
CITY:CHULA VISTASTATE: CAZIP CODE:
91911
CAPACITY: 4CENSUS: 3DATE:
04/17/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Administrator Veronica Gomez ZavalaTIME VISIT/
INSPECTION COMPLETED:
04:20 PM
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced visit to conduct a Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Administrator Veronica Gomez-Zavala. LPA also spoke via phone with Licensee Eduardo "Eddie" Gonzalez Jr. during the visit.

According to the facility’s license, the facility has a maximum capacity of four (4) clients, of whom all must be ambulatory. Based on staff and client interviews and LPA observation: During this annual inspection, there were a total of three (3) clients in care, of whom all were ambulatory in practice. The facility’s license did not include endorsements for delayed-egress doors or secured perimeter, and neither of these were present.

During this inspection, LPA toured the interior and exterior of the facility and inspected all common areas and bedrooms. LPA interviewed multiple clients and all staff who were present. LPA also reviewed the care and administrative records for all clients and the personnel and training files for all active staff. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were working. Extra linens, hygiene, and Personal Protective Equipment (PPE) supplies were present.


[CONTINUED ON LIC 809-C, 1 of 2]
NAME OF LICENSING PROGRAM MANAGER: Lizzette Tellez
NAME OF LICENSING PROGRAM ANALYST: Dang Nguyen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/17/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: MY BEST LIFE RESIDENTIAL
FACILITY NUMBER: 374604665
VISIT DATE: 04/17/2025
NARRATIVE
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[CONTINUED FROM LIC 809]

The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility’s ambient internal temperature was complaint at 69 F. Hot water temperature at taps accessible to clients were compliant in temperature: Kitchen Sink was 115.5 F, Bathroom #1 Sink was 113.9 F, and Bathroom #2 Sink was 113.2 F. Refrigerator and freezer used to preserve perishable food were also complaint in temperature. There were at least (2) days of perishable food and at least seven (7) days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present and in good condition.

The facility did not have a swimming pool (or similar body of water). The fireplace (which per staff is not used) was nonetheless screened. There were no open-faced heaters, toxic chemicals/poisons, or other hazardous objects accessible to clients. Smoke detectors, carbon monoxide detector, emergency lighting, night lights, and facility telephone were all working. The facility's fire extinguishers were serviced within the last twelve (12) months. Medications were in their original pharmacy packaging and were stored in a locked area. Confidential records were stored in locked areas. Required licensing postings were observed in visible areas of the facility. Per the Licensee, no firearms or ammunition were kept at the facility. Licensee presented proof of current business liability insurance and surety bond.

During a review of personnel and training records, LPA observed, and manager interview confirmed: Licensee did not maintain a complete and signed pre-employment physical / health screening for Staff #1 (S1) and Staff #2 (S2), as required. [See LIC811 Confidential Names List for a description of select person identifiers used in this report.] Client #1 (C1), who relied on facility staff for medication assistance, was prescribed an as-needed (PRN) medication inhaler by their doctor. C1 occasionally used this inhaler in practice, when they had symptoms. However, Licensee did not obtain “written documentation from [a] licensed professional outlining the procedures and the names of facility staff who have been trained in [inhaler assistance] procedures,” as required. Licensee did not have proof that all direct care staff had been trained on Personal Protective Equipment (PPE) within the last year, as required. Licensee did not ensure that all staff had been trained on the facility’s written LIC610D Emergency Disaster Plan within the last year, as required.

[CONTINUED ON LIC 809-C, 2 of 2]
NAME OF LICENSING PROGRAM MANAGER: Lizzette Tellez
NAME OF LICENSING PROGRAM ANALYST: Dang Nguyen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025
LIC809 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: MY BEST LIFE RESIDENTIAL
FACILITY NUMBER: 374604665
VISIT DATE: 04/17/2025
NARRATIVE
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[CONTINUED FROM LIC 809-C, 1 of 2]

Three (3) deficiencies were cited per California Code of Regulations, Title 22, and one (1) deficiency was cited per California Health and Safety Code (refer to the LIC809-D pages). Plans of Correction were jointly developed with the Licensee. LPA also issued one (1) Technical Violation (TV) regarding disaster drills for staff (refer to the LIC9102-TV page). LPA provided Technical Assistance (TA) regarding updating the administrator on record (refer to the LIC9102-TA page).

An exit interview was conducted with Administrator Veronica Gomez-Zavala, to whom a copy of this report, the LIC 809-D pages, the LIC9102-TV page, the LIC9102-TA page, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during today's visit.
NAME OF LICENSING PROGRAM MANAGER: Lizzette Tellez
NAME OF LICENSING PROGRAM ANALYST: Dang Nguyen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025
LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 04/17/2025 04:12 PM - It Cannot Be Edited


Created By: Dang Nguyen On 04/17/2025 at 03:06 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: MY BEST LIFE RESIDENTIAL
FACILITY NUMBER: 374604665

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85095.5(b)(2)(C)
Infection Control Requirements
(b) In addition to subsection (a), when one or more clients in the facility are diagnosed with a contagious disease, the following shall apply:  (2) All staff and volunteers providing direct care to a client who has a contagious disease shall wear appropriate Personal Protective Equipment (PPE) to prevent exposure to infectious agents or chemicals through the respiratory system, skin, or mucous membranes of the eyes, nose, or mouth.  PPE may include gloves, gowns, masks, respirators, shoe coverings and eye protection.  (C) The licensee shall ensure all staff and volunteers are trained in the proper use of all required PPE prior to being around clients and annually thereafter. 

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
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Based on record review and manager interview, Licensee did not ensure direct care staff received training on PPE within the last year, as required. This posed a potential health risk to 3 of 3 clients (C1 through Client #3) in care.
POC Due Date: 05/17/2025
Plan of Correction
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Licensee agreed to train all current staff on PPE. The training will include hands-on practice and will cover: a) handwashing, b) how and how often to disinfect commonly touched surfaces, c) how to correctly don and doff surgical masks, N-95 respirators, face shields, gowns, and gloves, d) how perform an N-95 seal check, and e) how to correctly set up a COVID-19 isolation bedroom. Licensee agreed to E-mail the training sign-in sheet to LPA, by the POC due date.
Type B
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review and manager interview, Licensee did not possess a completed and signed health screening for 2 of 6 staff (S1 and S2). This posed a potential health and safety risk to 3 of 3 clients (C1 through Client #3) in care.
POC Due Date: 05/17/2025
Plan of Correction
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Licensee agreed to coordinate with S1 and S2 to have each person complete a physical exam with their respective physician, and to obtain a complete and signed LIC503 Health Screening for S1 and S2 to place in their employee files. Licensee agreed to E-mail LPA a copy of S1 and S2's LIC503 forms, by the 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.
Lizzette Tellez
NAME OF LICENSING PROGRAM MANAGER:
Dang Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2025


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 04/17/2025 04:12 PM - It Cannot Be Edited


Created By: Dang Nguyen On 04/17/2025 at 03:06 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: MY BEST LIFE RESIDENTIAL
FACILITY NUMBER: 374604665

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(b)(1)(A)1
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (1) In adult CCFs, facility staff who receive training may assist clients with metered-dose inhalers, and dry powder inhalers if the following requirements are met: (A) In ARFs, facility staff must receive training from a licensed professional. 1. The licensee shall obtain written documentation from the licensed professional outlining the procedures and the names of facility staff who have been trained in those procedures.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review and manager interview, for 1 of 3 clients (C1) who used inahler devices to receive medication, Licensee did not ensure that the staff who assisted them were trained by a licensed professional on inhalers, as evidenced in written documentation from the licensed professional. This posed a potential health risk to persons in care.
POC Due Date: 05/17/2025
Plan of Correction
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Licensee agreed to coordinate with a licensed professional to have all current direct care staff trained on use of inhaler devices, and to document both the procedures staff are to follow and the names of the staff trained on them. Licensee agreed to E-mail proof of training completion to LPA, by the POC due date. Going forward, Licensee agreed to have a licensed professional review staff performance on inhalers at least once per year.
Type B
Section Cited
HSC
1565(b)
Other Provisions
(b) If a facility employs staff, the facility shall provide training on the plan to each staff member upon hire and annually thereafter. The training shall include staff responsibilities during an emergency or disaster.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and manager interview, Licensee did not ensure that each staff member received annual training on the facility's written emergency disaster plan, to include their individual responsibilities under it. This posed a potential safety risk to 3 of 3 clients (C1 through Client #3) in care.
POC Due Date: 05/17/2025
Plan of Correction
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3
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Licensee agreed to train all staff on the facility's written LIC610D Emergency and Disaster Plan. Licensee agreed to E-mail the training sign-in sheet to LPA, by the 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.
Lizzette Tellez
NAME OF LICENSING PROGRAM MANAGER:
Dang Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2025


LIC809 (FAS) - (06/04)
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