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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800231
Report Date: 11/20/2024
Date Signed: 11/20/2024 05:18:31 PM

Document Has Been Signed on 11/20/2024 05:18 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:HOME SWEET HOME ASSISTED LIVINGFACILITY NUMBER:
331800231
ADMINISTRATOR/
DIRECTOR:
CONDIT, CHRYSTALFACILITY TYPE:
740
ADDRESS:29510 SCOREBOARDTELEPHONE:
(951) 719-6124
CITY:LAKE ELSINORESTATE: CAZIP CODE:
92530
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 3DATE:
11/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:18 PM
MET WITH:Licensee/Administrator Chrystal ConditTIME VISIT/
INSPECTION COMPLETED:
05:25 PM
NARRATIVE
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On 11/20/2024 at 01:18 PM, Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA Brown met with a staff and was granted entry to the facility. Licensee/Administrator Chrystal Condit was informed of the visit and arrived at the facility during the visit. At the time of the visit there were two (2) staff present, and three (3) residents present.

The facility is a three (3) bedroom, two (2) bathroom home with a kitchen/dining area, living room/activity room, laundry room. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of six (6) non-ambulatory residents of which two (2) may be bedridden. The facility’s approved for four (4) hospice waiver. The current census is three (3) residents. LPA Brown was accompanied by Licensee/Administrator Condit to conduct a general overall inspection, which included, but was not limited to, the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 75 degrees Fahrenheit. LPA Brown inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA Brown observed sufficient furniture and lighting throughout the facility. LPA Brown measured and observed the water temperature in the bathroom to be at 107 degrees Fahrenheit. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Fire extinguisher was also observed at the facility. Posters such as personal rights, the CCLD complaint poster, and the disaster plan were posted in a common area. LPA Brown observed Resident #2 (R2) has half bed rail and per interview and documents review, R2 does not have a written order from R2 physician indicating the need for half bed rail for mobility. Deficiency will be issued. ***Continuation in LIC809C ***
Efren MalagonTELEPHONE: (951) 202-6356
Melody BrownTELEPHONE: 951-897-2187
DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/20/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: HOME SWEET HOME ASSISTED LIVING
FACILITY NUMBER: 331800231
VISIT DATE: 11/20/2024
NARRATIVE
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Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated storage space for resident/staff files. There is a Medicine closet with the resident’s medications locked. LPA Brown observed the complete first aid kit and first aid book at the facility.

Food Service: More than seven (7) days’ supply of Non-perishable foods and more than two (2) days’ supply of perishable food supply were observed and sufficient for the number of residents in care.

Care & Supervision: The facility has an Administrator present at the facility with appropriate and enough hours to appropriately manage the facility. The facility has sufficient number of staff to provide care and supervision to the residents in care.

Record Review: LPA Brown observed the facility has an updated liability insurance. LPA Brown did not observe Infection Control Plan maintained at the facility. Deficiency will be issued. LPA Brown reviewed two (2) resident files for admission agreements, updated physician reports, pre-placement appraisals, centrally stored medication list and needs and services plans. LPA Brown observed no completed preplacement needs and services plan for Resident #1 (R1) and Resident #2 (R2). Deficiency will be issued. LPA Brown observed incomplete Centrally Stored Medications list for Resident #1 (R1) and Resident #2 (R2). Deficiency will be issued. LPA Brown reviewed two (2) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test result. LPA Brown observed no documentation of the required 40 Hours training provided to Staff #2 (S2). Deficiency will be issued. LPA Brown observed no additional 20 hours annual training were provided to Staff #2 (S2). Deficiency will be issued. LPA Brown observed Staff #2 (S2) does not have the required four (4) hours of medication training and S2 and Staff #3 (S3) do not have the required six (6) hours of hands-on shadowing training. Deficiency will be issued.

LPA Brown observed no medication record at the facility for Resident #1 (R1) and Resident #2 (R2) and there's no proof to show that staff at the facility are assisting R1 with R1 medication per R1's doctor's order as one (1) medication of R1's missing and no medication record was maintained at the facility to show medication was given per R1's physician order. Deficiency will be issued.



In addition, LPA Brown observed the facility does not have the required emergency supplies, food and water maintained at the facility. Deficiency will be issued. Also, LPA Brown observed that the Licensee did not review, sign and date the Emergency Disaster Plan. Deficiency will be issued.
***Continuation in LIC809C***
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/20/2024 05:18 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


FACILITY NAME: HOME SWEET HOME ASSISTED LIVING

FACILITY NUMBER: 331800231

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/20/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Other Provisions
(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above by not ensuring that Staff #2 (S2) completed the required 40 hours training which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/21/2024
Plan of Correction
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Licensee stated to submit proof of S2 registration to complete the required training or completed 40 hours certification to LPA Brown on Plan of Correction (POC) due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Efren MalagonTELEPHONE: (951) 202-6356
Melody BrownTELEPHONE: 951-897-2187

DATE: 11/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2024

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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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


FACILITY NAME: HOME SWEET HOME ASSISTED LIVING

FACILITY NUMBER: 331800231

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/20/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Other Provisions
(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that Staff #2 (S2) have the required four (4) hours of medication training and S2 and Staff #3 (S3) have the required six (6) hours of hands-on shadowing training which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/21/2024
Plan of Correction
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Licensee stated to submit proof of registration to complete the required training or completed certification to LPA Brown on Plan of Correction (POC) due date.
Section Cited
Incidental Medical and Dental Care Services
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that staff at the facility's assisting Resident #1 (R1) with one (1) of R1's medication as medication was not at the facility and no medication record was maintained at the facility that will show R1's medication was given per R1's physician order which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/21/2024
Plan of Correction
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Licensee stated to train all staff on CCR 87465(a)(4) and submit proof to LPA Brown on POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Efren MalagonTELEPHONE: (951) 202-6356
Melody BrownTELEPHONE: 951-897-2187

DATE: 11/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2024

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/20/2024 05:18 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


FACILITY NAME: HOME SWEET HOME ASSISTED LIVING

FACILITY NUMBER: 331800231

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/20/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above by not ensuring that Resident #1 (R1) and Resident #2 (R2) have a completed Centrally Stored Medication list which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/21/2024
Plan of Correction
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Licensee stated to train all staff on CCR87465(a)(6) and submit proof to LPA Brown on Plan of Correction (POC) due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Efren MalagonTELEPHONE: (951) 202-6356
Melody BrownTELEPHONE: 951-897-2187

DATE: 11/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2024

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/20/2024 05:18 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


FACILITY NAME: HOME SWEET HOME ASSISTED LIVING

FACILITY NUMBER: 331800231

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/20/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not developing the required Infection Control Plan for the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/06/2024
Plan of Correction
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Licensee stated to develop and submit a copy of Infection Control Plan to LPA Brown on Plan of Correction (POC) due date.
Section Cited
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that Staff #2 (S2) completed the required 20 hours training annuallywhich poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/06/2024
Plan of Correction
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Licensee stated to submit a copy of S2 compketed certification on the required 20 hours annual training to LPA Brown on POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Efren MalagonTELEPHONE: (951) 202-6356
Melody BrownTELEPHONE: 951-897-2187

DATE: 11/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2024

LIC809 (FAS) - (06/04)
Page: 6 of 11
Document Has Been Signed on 11/20/2024 05:18 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


FACILITY NAME: HOME SWEET HOME ASSISTED LIVING

FACILITY NUMBER: 331800231

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/20/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Other Provisions
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that teh afcility has the required emegency supplies, food and water which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/06/2024
Plan of Correction
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Licensee stated to obtain/purchase/prepare the required emergency supplies, food, and water and submit proof to LPA Brown on Plan of Correction (POC) due date.
Section Cited
Other Provisions
(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee or administrator shall sign and date documentation to indicate that the plan has been reviewed and updated as necessary.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not reviewing, signing and date the Emergency Disaster Plan as required which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/06/2024
Plan of Correction
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Licensee stated to review, sign and date the Emergency Disaster Plan as required and submit proof to LPA Brown on POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Efren MalagonTELEPHONE: (951) 202-6356
Melody BrownTELEPHONE: 951-897-2187

DATE: 11/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2024

LIC809 (FAS) - (06/04)
Page: 7 of 11
Document Has Been Signed on 11/20/2024 05:18 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


FACILITY NAME: HOME SWEET HOME ASSISTED LIVING

FACILITY NUMBER: 331800231

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/20/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Other Provisions
(e) A facility shall have all of the following information readily available to facility staff during an emergency: (2) An appraisal of resident needs and services plan for each resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that Resident #1 (R1) and Resident #2 (R2) have a completed Preplacement Needs and Services Plan maintained in their facility file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/06/2024
Plan of Correction
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Licensee stated to submit a completed copies of R1 and R2 Preplacement Needs and Services Plan to LPA Brown on Plan of Correction (POC) due date.
Section Cited
Postural Supports
(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by allowing Resident #2 (R2) to have a half bed rail without written order from R2 physician indicating the need for half bed rail for mobility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/06/2024
Plan of Correction
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Licensee stated to obtain R2 physician order for R2 half bed rail for mobility and submit proof to LPA Brown on POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Efren MalagonTELEPHONE: (951) 202-6356
Melody BrownTELEPHONE: 951-897-2187

DATE: 11/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2024

LIC809 (FAS) - (06/04)
Page: 8 of 11
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: HOME SWEET HOME ASSISTED LIVING
FACILITY NUMBER: 331800231
VISIT DATE: 11/20/2024
NARRATIVE
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Moreover, LPA Brown observed Resident #2 (R2) does not have the annual medical assessment as required for resident with dementia. Deficiency will be issued.

Based on the observations made during today’s visit, deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809), LIC809D and Appeal Rights were discussed and provided to Licensee/Administrator Chrystal Condit.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2024
LIC809 (FAS) - (06/04)
Page: 10 of 11
Document Has Been Signed on 11/20/2024 05:18 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


FACILITY NAME: HOME SWEET HOME ASSISTED LIVING

FACILITY NUMBER: 331800231

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/20/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
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3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above by not ensuring that Resident #2 (R2) has an updated annual physician report as required for residents with dementia which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/21/2024
Plan of Correction
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2
3
4
Licensee stated to submit a medical appointment date/updated Physician Report for R2 to LPA Brown on Plan of Correction (POC) due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Efren MalagonTELEPHONE: (951) 202-6356
Melody BrownTELEPHONE: 951-897-2187

DATE: 11/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2024

LIC809 (FAS) - (06/04)
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