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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700373
Report Date: 06/01/2023
Date Signed: 06/01/2023 11:21:10 AM

Document Has Been Signed on 06/01/2023 11:21 AM - 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:HOME SWEET HOME - ASSISTED LIVING FACILITYFACILITY NUMBER:
342700373
ADMINISTRATOR:MEZA, LILIBETHFACILITY TYPE:
740
ADDRESS:8890 HARLOW CTTELEPHONE:
(916) 661-2940
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 5DATE:
06/01/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Lilibeth MezaTIME COMPLETED:
11:30 AM
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On 6/1/23 at approximately 9:30am Licensing Program Analysts (LPAs) Maja Jensen and Jennifer Fain arrived unannounced to conduct a health and safety check. On 7/14/22 a Non-Compliance conference was held and the Department is conducting increased monitoring as a result of deficiencies that were cited. LPA's Jensen and Fain met with Licensee Lilibeth Meza and explained the purpose of today's visit.

Upon arrival LPA Jensen observed 2 staff members present. Neither of the 2 staff members were associated to the facility based on LPA Jensen's verification through Guardian. LPA Jensen interviewed the Licensee who stated she attempted to associate Staff 1 (S1) on 5/12/23 but it appears the needed information was not attached to the request in error. The Licensee stated that Staff 2 (S2) is not associated to the facility as she is not regular staff, she was only called to the facility on this date to assist with a resident shower and this is the first time she has ever been at the facility.

LPA Jensen reviewed the Administrator's certificate which is current through November of 2023. LPA Jensen reviewed the LIC 500 which shows the Administrator is scheduled to be present at the facility Monday through Friday from 12pm to 3:30pm and from Friday 7pm to Saturday 7pm. LPA Fain reviewed 5 of 5 resident files and determined 5 of 5 files had current LIC 602's and Needs and Service Plans.

LPA Jensen reviewed the Licensing Information System and determined the Licensing Fees have not been paid since 11/4/2020.

Deficiencies are being cited from the California Code of Regulations (CCR) and the Health and Safety Code (HSC). Civil Penalties are being assessed for Caregiver Background Check violations.

An exit interview was conducted and a copy of this report, the LIC 811 and appeal rights were provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 06/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/01/2023
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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Document Has Been Signed on 06/01/2023 11:21 AM - It Cannot Be Edited


Created By: Maja Jensen On 06/01/2023 at 10:18 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: HOME SWEET HOME - ASSISTED LIVING FACILITY
FACILITY NUMBER: 342700373

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/02/2023
Section Cited
CCR
87411(g)

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87411 Personnel Requirements - General
...
Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall:

(1) Obtain a California clearance or a criminal record exemption as required by law or Department regulations or

(2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

(3) Request and be approved for a transfer of a criminal record exemption, as specified in Section 87356(r), unless, upon request for a transfer, the Department permits the individual to be employed, reside or be present at the facility. This requirement was not met as evidenced by:
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The Licensee agrees to associate the employees by the Plan of Correction due date.
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Based on LPA Jensen's observation of 2 of 2 staff members who were present at the facility and not associated to the facility as determined by a record review in Guardian. This poses an immediate threat to the health, safety and personal rights of residents in care.
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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.
SUPERVISOR'S NAME:Liza King
LICENSING EVALUATOR NAME:Maja Jensen
LICENSING EVALUATOR SIGNATURE:
DATE: 06/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/01/2023 11:21 AM - It Cannot Be Edited


Created By: Maja Jensen On 06/01/2023 at 10:23 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: HOME SWEET HOME - ASSISTED LIVING FACILITY
FACILITY NUMBER: 342700373

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/08/2023
Section Cited
HSC
1569.185(e)

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Fees for license or applications; use of revenues; collected; denial or forfeiture The failure of an applicant for licensure or a licensee to pay all applicable and accrued fees and civil penalties shall constitute grounds for denial or forfeiture of a license. This requirement was not met as evidenced by:
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The Licensee agrees to bring the account current by the Plan of Correction due date and will email maja.jensen@dss.ca.gov confirming completion of the Plan of Correction (POC) by the POC due date.
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Based on LPA Jensen's review of the Licensing Information System the Licensing fees are not current. This poses a potential risk to the health, safety and personal rights of residents in care
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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.
SUPERVISOR'S NAME:Liza King
LICENSING EVALUATOR NAME:Maja Jensen
LICENSING EVALUATOR SIGNATURE:
DATE: 06/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2023


LIC809 (FAS) - (06/04)
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