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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216803604
Report Date: 10/09/2023
Date Signed: 10/09/2023 11:39:26 AM

Document Has Been Signed on 10/09/2023 11:39 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
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:
10/09/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator, Justine Herrera TIME COMPLETED:
11:50 AM
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At approximately 9:30AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a Required 1 Year visit and met with Staff Member, Teresita Tuveria. Administrator, Justine Herrera, arrived during visit at approximately 9:50AM. Upon arrival, LPA was informed that there were 6 Residents in care and 2 staff members on-site.

At approximately 9:40AM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. LPA reviewed 6 resident files and 6 resident medication records. Resident files were all found to be well organized, thorough and contained the required documentation. Medication was found to be centrally stored and secure.

LPA requested the following documents to update facility file:
  • Designation of Facility Responsibility (LIC 308)
  • Emergency Disaster Plan (LIC 610D)
  • Updated Personnel Report (LIC 500)
  • Register of Clients/Residents (LIC 9020)
  • Updated Liability Insurance
  • Active and Current Administrator Certificate

Facility Documents to be submitted to Community Care Licensing (CCL) by due date of Thursday, 11/09/2023.

No Deficiencies Cited during visit.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 10/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/09/2023
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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