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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920138
Report Date: 07/16/2024
Date Signed: 07/16/2024 11:09:51 AM

Document Has Been Signed on 07/16/2024 11:09 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:FAMILY LIFE SENIOR CAREFACILITY NUMBER:
345920138
ADMINISTRATOR/
DIRECTOR:
LUCA, DANIELFACILITY TYPE:
740
ADDRESS:7662 COPPER COVE PLACETELEPHONE:
(415) 619-8275
CITY:ANTELOPESTATE: CAZIP CODE:
95843
CAPACITY: 6CENSUS: 6DATE:
07/16/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Administrator- Daniel LucaTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
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On 07/16/24 Licesning Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility announced to conduct a Pre- Licensing visit. LPA met with Administrator, Daniel Luca to conduct Pre- Licensing visit. This application is a change in ownership (CHOW). This address is currently licensed as Silvana Senior Care 3, #342700982. Administrator holds a current administrator certificate (#6068764740 with expiration date 09/04/26). The facility currently has six (6) resident during today's inspection. Facility has a fire clearance for six (6) non-ambulatory residents.

LPA and Administrator conducted a tour of the interior and exterior of the facility. Areas toured include but not limited to: five (5) resident bedrooms, two (2) bathrooms, kitchen, living room, laundry room and common areas. Resident bedrooms were properly furnished and maintained. Bathrooms were observed to be clean and sanitary. Facility food supply is in compliance with two (2) days of perishable and seven (7) days of non-perishable food items. Smoke and carbon monoxide detectors are operational. The Fire extinguisher was serviced on 01/16/24. Grab bars were present at the toilet and in the shower. All exits were unobstructed. All toxins, medications, and sharps were locked and stored away. Facility's temperature was 75 degrees Fahrenheit during inspection. Hot water temperature was observed to be 119.8 degrees Fahrenheit, which is within the required range of 105-120 degree. First aid kit found to be complete. Required postings are posted throughout the facility.

LPA reviewed one (1) resident file and one (1) staff and found that all required paperwork was present. Additionally, LPA provided administrator with a copy of LIC311F, records to be maintained at the facility.

Pre-licensing passed and Component III was completed. Applicant has satisfied all requirements in accordance to Title 22, California Code of Regulations. Application is pending and LPA will forward findings to the Centralized Application Bureau (CAB) for final review and approval. CAB will further contact applicant on final status of application. Exit interview conducted and a copy of this report was left at the facility.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE: DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/16/2024
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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