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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803604
Report Date: 07/23/2021
Date Signed: 07/23/2021 11:05:45 AM

Document Has Been Signed on 07/23/2021 11:05 AM - 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:LONG LIFE LIVING INC IIIFACILITY NUMBER:
216803604
ADMINISTRATOR:CHANG, FAYEFACILITY TYPE:
740
ADDRESS:36 MT. FORAKER DRIVETELEPHONE:
(415) 479-4890
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY: 6CENSUS: 6DATE:
07/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Administrator, Faye ChangTIME COMPLETED:
11:20 AM
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), Farhaan Sarangi arrived unannounced at Long Life Living III for the purpose of conducting a Required 1-year inspection. LPA met with Administrator, Faye Chang and was granted access into the facility.

LPA toured the facility with Administrator, Faye Chang. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Exits were equipped with auditory devices and all were working properly. Smoke detectors and carbon monoxide detectors were found to be operational during the visit. Hot water temperature measured within Title 22 acceptable regulation of 105 to 120 degrees F. The facility serves residents with dementia and has a plan of operation for special care and programming. There was a sufficient supply of both perishable and nonperishable food as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored in a facility garage. There was a supply of cleaners, hygiene products and paper products available for residents. The bathrooms designated for residents at the facility were supplied with paper towels and hand soap dispensers. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom shower. All bedrooms have lighting & appropriate furnishings. Resident’s beds were outfitted with mattress pads as required by Title 22 Regulations. Fire Extinguisher was found to be last charged on June 2019. Facility will be having fire extinguishers inspected today, July 23, 2021.

LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Facility has PPE supply stored in the storage office located in the staff room. Staff have had all PPE training required on fill. Staff are N95 Fit tested.

No deficiencies cited during today's Required 1- Year inspection. Exit interview was conducted and a copy of this report was emailed to the facility Administrator, Faye Chang.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 07/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/23/2021
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 2