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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800231
Report Date: 11/04/2020
Date Signed: 11/04/2020 01:16:09 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:HOME SWEET HOME ASSISTED LIVINGFACILITY NUMBER:
331800231
ADMINISTRATOR:CONDIT, CHRYSTALFACILITY TYPE:
740
ADDRESS:29510 SCOREBOARDTELEPHONE:
(951) 719-6124
CITY:LAKE ELSINORESTATE: CAZIP CODE:
92530
CAPACITY:5CENSUS: 3DATE:
11/04/2020
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Licensee, Crystal ConditTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) David Cuevas conducted an announced visit, per Licensee’s request via FaceTime due to COVID restrictions. The purpose of today’s visit is intended to observe and inspect current floor plan to ensure facility is complaint with updated fire clearance. Facilities new fire clearance inspection approved reflects an increase of capacity from 5 to 6 non-ambulatory residents, room # 3 will now be a shared bedroom. LPA Cuevas observed room to be properly furnished, beds to have proper bedding, and a walk in closet with enough space for residents personal belongings.

LPA along with Licensee toured facility and observe, all passageways clear of obstructions and facility to be following special conditions set forth by local fire department. Smoke detector/carbon monoxide detector in bedroom # 3 was tested and observed to be operational. LPA observed fire extinguishers to be full last services September 2020. No deficiencies or civil penalties accessed during today’s visit.

An exit interview was conducted with Licensee via Face Time were this report was reviewed and a copy provided via email with facility representative signature requested.

SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: David CuevasTELEPHONE: (951) 295-3927
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2020
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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