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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700373
Report Date: 07/29/2024
Date Signed: 07/29/2024 04:56:34 PM


Document Has Been Signed on 07/29/2024 04:56 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: 5DATE:
07/29/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Lilibeth MezaTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on a subsequent complaint visit on 7/29/24 at 12p. LPA met with Lilibeth Meza and stated the purpose of the visit.

During the complaint investigation (27-AS-20240506114555), LPA observed that the LIC602 Physician Report for resident #1 (R1) dated 2/25/24 was incomplete in areas such as section 14 Mental Condition, and 16 Medication Management which did not indicate the abilities of R1.

Community Care Licensing (CCL) received a LIC624 Unusual Incident/Injury Report dated 5/5/24 indicating R1 was sent to emergency room on 5/4/24 around midnight due to possible fall. The Licensee also stated on the SIR that R1 had a history of elopement. The SIR further mentions that Staff #1 (S1) saw R1 sitting on the ground at the house next door at which time S1 guided R1 to walk back to the facility. During an interview with the witness and S1, LPA obtained information that S1 actually carried R1 back to the facility while R1 was in pain.

In addition, LPA observed a hospital discharge summary indicating that R1 was admitted to hospital on 5/4/24 at which time R1’s injuries included: left frontotemporal scalp hematoma and left 4-7 ribs fractured. S1 stated that R1 was holding chest area while outside on the ground.
In reviewing the facility on-going notes LPA observed written by S2:
-2/5/24 R1 fell and 911 was initiated and taken to hospital.
-3/3/24 R1 was having pain in rib area which was brought to Licensees attention.
-4/19/24 R1 fell hitting head on dresser with 101*F temperature and blood sugar level at 251 and 911 was initiated.
During interviews the responsible party was made aware of the falls but not the elopement in a timely manner. Also, as a result of a fall during the elopement, R1 incurred major injuries.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2024
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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Document Has Been Signed on 07/29/2024 04:56 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
07/30/2024
Section Cited
HSC
1569.49(f)

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For a violation that the department determines constitutes physical abuse, as defined in Section 15610.63 of the Welfare and Institutions Code, or resulted in serious bodily injury, as defined in Section 15610.67 of the Welfare and Institutions Code, to a resident, the civil penalty shall be ten thousand dollars ($10,000).
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Licensee shall submit a statement understanding and that the regulations will be adhered to at all times. Submit by fax by POC due date.
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This requirement is not met as evidenced by: Based on interviews, documentation, and medical records, R1 fell outside the facility during elopment with supervision which required medical attention. This violation poses an immediate health, and safety risk to residents in care.
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Type A
07/30/2024
Section Cited
CCR87207

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False Claims

No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility.
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Licensee shall submit a statement understanding of regulations and that all statements submitted to CCL shall not be misleading. Submit by fax by POC due date.
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This requirement is not met as evidenced by:
Based on interviews Licensee did not ensure reporting the correct information regarding resident safety and care needs.
This poses an immediate health and safety risk to 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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/29/2024 04:56 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/30/2024
Section Cited
CCR
87506(a)

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Resident Records
The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff
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Licensee shall submit a statement understanding and that all files will be completed, signed, and dated, at all times. Submit by fax by POC due date.
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This requirement is not met as evidenced by: Based on observation of documentation Licensee did not ensure physician report was complete dor R1. This violation poses an immediate health, and safety risk to residents in care.
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Type A
07/30/2024
Section Cited
CCR87468.1(a)(9)

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Personal Rights of Residents in All Facilities
To have communications...their representatives...promptly...
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Licensee shall submit a statement of understanding and that all responsible parties received updates regarding the residents care and supervision in a timely manner at all times. Submit by fax by POC due date.
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This requirement is not met as evidenced by: Based on interviews, Licensee di dnot ensure responsible party was made aware of residents elopment, fall, and/or hospitalization in a timely manner. This violation poses an immediate health, and safety risk to 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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 FACILITY
FACILITY NUMBER: 342700373
VISIT DATE: 07/29/2024
NARRATIVE
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You are hereby notified that a civil penalty of $500.00 is assessed for a violation that resulted in serious bodily injury/serious injury of a client, or that constitutes physical abuse of a client. The licensee was informed that a civil penalty assessment based on Health and Safety Code 1569.49(f) is currently under review (pending determination) and may be assessed on a later date, as a result of R1’s sustaining fractures (serious bodily injury) while in care of the facility. Once civil penalty assessment has been determined, CCL will return on a future date to assess the civil penalty.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 809D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. The Licensee representative was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted with Licensee representative and a copy of this report was provided.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024
LIC809 (FAS) - (06/04)
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