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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700373
Report Date: 10/15/2021
Date Signed: 10/15/2021 04:53:54 PM

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:
10/15/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:53 PM
MET WITH:Herminia OloteoTIME COMPLETED:
05:06 PM
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On 10-15-21 at 2:51pm, Licensing Program Analyst (LPA) Michael Bilger arrived at this facility unannounced to conduct an annual inspection visit. LPA met with lead caregiver Herminia Oloteo and explained the purpose of the visit. LPA spoke with Administrator Lilibeth Meza who was not present and gave permission for lead caregiver to sign in her absence. Administrator arrived at facility at 4:15pm.

LPA Bilger inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common TV area, and outside backyard of the facility to ensure compliance with Title 22 regulations. Facility is a 6 bed residential care facility for the elderly (RCFE) with a current census of 5. Facility has a formal living room and dining room.There are 4 bedrooms and 2 bathrooms. LPA also conducted the infection control domain tool.
The facility has an approved COVID Mitigation plan LIC 808 form in place.The facility has central entry point and has implemented screening and sign in procedures at the front door area. The facility conducts routine symptom screening for employees, residents, and visitors. LPA observed the facility to have hand washing, COVID - 19 informational, and social distancing signs posted throughout the facility, on the front door, and back yard. The facility has a designated infection control lead. The facility is able to designate and dedicated a Covid-19 room/bathroom if needed. Common touch surfaces are cleaned after each use. LPA reviewed 7 staff files. All criminal backgound clearances and current first aid/cpr certification verified.

Water temperature reads 113.3*F in the bathroom and room temperature reads 74*F. LPA observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguisher was checked 9/28/21. Facility has an emergency food and water kit. No obstructions to emergency exits noted.
Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was held with Administrator Lilibeth Meza and a copy of this report was given to Lilibeth
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2021
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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