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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602143
Report Date: 05/08/2021
Date Signed: 05/08/2021 06:14:47 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:HOME SWEET HOME IIFACILITY NUMBER:
197602143
ADMINISTRATOR:ALFONSO DE LA CUESTAFACILITY TYPE:
740
ADDRESS:23788 VIA JACARATELEPHONE:
(661) 254-3336
CITY:VALENCIASTATE: CAZIP CODE:
91355
CAPACITY:6CENSUS: 5DATE:
05/08/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Alfonso De La CuestaTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Yelena Avetisyan conducted an unannounced Case Management - Deficiencies inspection visit at the facility today due to deficiencies observed during the investigation of complaint control #31-AS-20201125164925.

Upon arrival LPA met with staff Alex Ignacio who contacted the administrator via telephone. Administrator arrived approximately 3:10 pm. While waiting for the administrator LPA had a discussion with staff about visitor screening as it was not done properly upon LPA's arrival.

Approximately 3:05 pm LPA conducted a brief tour of the facility. While touring the facility LPA inquired about the resident in Room #1 and Room # 2. According to staff they reposition the 2 residents in the rooms every 2 hours. Staff confirmed that the residents are unable to reposition on their own.

Approximately 3:15 pm LPA spoke with the administrator regarding the facility fire clearance. LPA informed administrator that resident 1 (R1) and resident 2 (R2) are bedridden however the licensees approved fire clearance is for 6 non-ambulatory. LPA informed the administrator that this is a zero tolerance violation.

A discussion was also held with administrator regarding training staff with the information that was approved by the department related to the licensees mitigation plan including but not limited to visitor screening. Administrator was informed that LPA will discuss the issue upon return to the Regional Office and contact him should additional follow be required.

In regards to the deficiencies observed during the course of the investigation for the above listed complaint control number the following was identified:

On 11/30/2020 LPA requested a current LIC 500, staff schedule from the administrator via email. On 12/1/2020 LPA conducted interview with administrator and confirmed the names of staff who were listed on the staff schedule.

SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2021
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: HOME SWEET HOME II
FACILITY NUMBER: 197602143
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/08/2021
Section Cited

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(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
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Based on record review and interview conducted licensee did not comply with the cited section by not transferring criminal record clearance for staff 1 prior to employment which poses an immediate health, safety or personal rights risk to persons in care.
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This is a Zero Tolerance violation, therefore , Civil penalty in the amount of $500 dollars has been issued.
Type A
05/09/2021
Section Cited

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87202 (a) (2) FIRE CLEARANCE. All facilities shall maintain a fire clearance. Prior to accepting persons over 60 years of age none ambulatory and/or bedridden the licensee shall notify the licensing agency and obtain an appropriate fire clearance.
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This requirement is not met as evidenced by: Based on observations made and interview with staff the licensee did not comply with the cited section by retaining two bedridden resident without proper fire clearance which poses an immediate health, safety or personal rights risk to persons in care.
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This is a zero tolerance violation therefore civil penalty in the amount of $500 has been issued. Administrator was informed that civil penalties will continue to accrue until POC is completed.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:
DATE: 05/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: HOME SWEET HOME II
FACILITY NUMBER: 197602143
VISIT DATE: 05/08/2021
NARRATIVE
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Based on the review of the provided documents and interview with the administrator LPA observed that staff 1 (S1)'s criminal record clearance was not transferred to this facility prior to employment. Per administrator they had a caregiver who was injured in October 2020 and was placed on light duty. S1 who was a reliever staff replaced the injured staff until 11/15/2020.

During the visit LPA discussed the importance of requesting a criminal record clearance and/or transfer of criminal record clearance prior to having any staff working or volunteering at the facility.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D).



Exit interview conducted, copy of report and appeal rights emailed to the administrator
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Yelena AvetisyanTELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2021
LIC809 (FAS) - (06/04)
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