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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002966
Report Date: 08/23/2022
Date Signed: 08/23/2022 12:05:53 PM


Document Has Been Signed on 08/23/2022 12:05 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:SWEET HOME CAREFACILITY NUMBER:
306002966
ADMINISTRATOR:NICOLETA BLAGAFACILITY TYPE:
740
ADDRESS:14681 WILSON STREETTELEPHONE:
(714) 901-0705
CITY:MIDWAY CITYSTATE: CAZIP CODE:
92655
CAPACITY:6CENSUS: 6DATE:
08/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:22 AM
MET WITH:Nicoleta BlagaTIME COMPLETED:
12:15 PM
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On 08/23/2022, Licensing Program Analyst (LPA) Jessica Cho conducted an unannounced visit to Sweet Home Care. The purpose of today's visit was to conduct a Required 1 Year focusing primarily on the Infection Control. At 10:29am, LPA Cho was allowed entry into the facility and met with Caregiver Semidia Sardea after completing the Coronavirus 2019 (COVID-19) screening procedure. Caregiver Annmarie Dacosta was also present at this time. Administrator (Admin) Nicoleta Blaga arrived at the facility around 11:00am. As of today, there are no active COVID-19 cases in the facility. Facility screens and documents temperatures for visitors on a sign in sheet. LPA observed the required COVID-19 precautionary signs posted on the front doors and throughout the facility. The Complaint Poster (PUB475) was observed in the required sizing. The facility is licensed for six non-ambulatory residents and has a hospice waiver for three. There are currently six residents living in the facility of which one is receiving hospice care. The Administrator's Certificate for Nicoleta Blaga expires on 02/09/2023.

Around 10:50am, LPA Cho conducted a tour of the physical plant along with Administrator Blaga and Caregiver Dacosta. The single story home consists of five resident bedrooms with four resident bathrooms. The facility also has a living room, family room, dining room, kitchen, laundry room, and an attached two car garage. The resident bedrooms had the required furnishings, bed linens, and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, showers were free of mold/mildew, and a non-skid mat was in place. Resident bath towels and personal hygiene supplies were adequately stocked including paper towels and hand soaps. LPA observed hand washing signs in all bathrooms. LPA Cho tested the hot water temperature in the resident bathrooms and the temperatures measured at 117.6 degrees Fahrenheit in the Bathroom #1, 116.0 degrees Fahrenheit in Bathroom #2, 115.5 degrees Fahrenheit in Bathroom #3, and 114.4 degrees Fahrenheit in Bathroom #4.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: SWEET HOME CARE
FACILITY NUMBER: 306002966
VISIT DATE: 08/23/2022
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LPA Cho inspected the kitchen along with Admin. Perishable and non-perishable food supplies were checked and adequately stocked at the time of the visit. The fire extinguisher was fully charged. The smoke and carbon monoxide detectors were tested and operational. Medications, toxins, and sharps were locked and inaccessible to the residents. The auditory alarms throughout the facility were in operating condition.

LPA Cho toured the outside grounds. There were no bodies of water present. There was shading and sufficient seating for residents. Walkways around the home were clear of hazards, and the exit gates were self-closing and self-latching. There were no security bars or weapons on the premises. There were two locked sheds that stored old furniture.



LPA Cho reviewed the Emergency and Disaster Plan for Residential Care Facilities for the Elderly (LIC610E). Facility does have back-up emergency food and water supply. The First Aid Kit met all the required components except the first aid manual, and the facility had sufficient PPEs.

No resident or staff files were reviewed at the time of this visit. LPA reviewed the COVID-19 mitigation plan of the facility as well as Assembly Bill (AB) 665. This bill would require residential facilities serving adults, residential care facilities for persons with chronic life-threatening illness, and residential care facilities for the elderly with existing internet service to provide at least one internet access device that can support real-time interactive applications, is equipped with video conferencing technology, and is dedicated for client or resident use. The facility does have an existing internet service and provides a smart phone upon request.

LPA provided the following guidance: to obtain a first aid manual. In addition, LPA reminded the importance of staying abreast with CCLD's COVID-19 guidance by reviewing and printing the Provider Information Notices (PINs) as well as by attending the CCLD Informational Calls. The PINs can be accessed at: www.ccld.ca.gov.

Based on the observations made during today's visit, no deficiency is cited in this review as per Title 22 Division 6 of the California Code of Regulations. Advisory Note (LIC9102) was issued during the visit. An exit interview was conducted with Administrator Nicoleta Blaga, and a copy of this report was provided.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2022
LIC809 (FAS) - (06/04)
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