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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700373
Report Date: 11/30/2023
Date Signed: 11/30/2023 12:34:27 PM


Document Has Been Signed on 11/30/2023 12:34 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:HOME SWEET HOME - ASSISTED LIVING FACILITYFACILITY NUMBER:
342700373
ADMINISTRATOR:MEZA, LILIBETHFACILITY TYPE:
740
ADDRESS:8890 HARLOW CTTELEPHONE:
(916) 509-9159
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:6CENSUS: 4DATE:
11/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Marie WalkerTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required - 1 Year visit on 11/30/23 at 10:00am. Administrator Certificate expires 6/11/24 for Jonalyn Gayao.

LPA met with Marie Walker, Caregiver who contacted the Administrator Lilibeth Meza regarding the purpose of todays visit. Lilibeth Meza, Adm arrived within 15 minutes to assist with todays visit. The facility is licensed for a capacity of 6 non-ambulatory residents of which 1 may receive hospice services. There is 0 residents receiving hospice care services during this visit. LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed 2-day perishables and 7-day non-perishables.

The temperature inside the facility was observed to be at 70*F which is within the required range of 68-85*F. The hot water temperature was measured at 120.0*F which is within the required range of 105-120*F. LPA observed fire extinguisher(s), smoke and carbon monoxide detectors, and central heating and air in the facility.

LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. LPA reviewed 2 staff and 2 resident files and conducted interviews during this visit.

LPA observed that the annual documents along with any changes were submitted prior to todays visit.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies cited. Exit interview held, copy of report given
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2023
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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