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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920138
Report Date: 12/12/2024
Date Signed: 12/12/2024 01:55:16 PM

Document Has Been Signed on 12/12/2024 01:55 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
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: 4DATE:
12/12/2024
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:05 PM
MET WITH:Administrator- Daniel LucaTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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On 12/12/24 Licensing Program Analysts (LPAs) Cheyenne Ratajczak and Graham Gunby arrived at the facility unannounced to conduct a post licensing inspection. LPAs met with Administrator Daniel Luca and explained the purpose of the visit.

LPAs and Administrator conducted a tour of the interior and exterior of the facility. Areas toured include but not limited to: resident bedrooms, bathrooms, kitchen, living 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. Required postings are posted throughout the facility.

LPAs reviewed four (4) resident files. Resident files contain signed admission agreements, physician's reports, appraisals, identification sheets, releases, and resident's rights. Medications are centrally stored, locked, and appear to be given per doctor order. LPAs compared medications to those being given for two (2) residents and found no discrepancies. Facility is correctly using the Medication Administration Records (MAR). LPAs reviewed two (2) staff record. Staff has training in infection control, first aid and CPR, and other various areas of care provision.

No deficiencies being cited during today's inspection.

Exit interview conducted and a copy of the report was left at the facility.

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2024
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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