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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700662
Report Date: 06/17/2021
Date Signed: 06/17/2021 02:55:01 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 II ASSISTED LIVING FACILITYFACILITY NUMBER:
342700662
ADMINISTRATOR:MEZA, LILIBETHFACILITY TYPE:
740
ADDRESS:8781 KELSEY DRIVETELEPHONE:
(916) 661-2940
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:6CENSUS: 5DATE:
06/17/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Lilibeth Meza, Administrator TIME COMPLETED:
02:15 PM
NARRATIVE
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On 06/17/2021, Licensing Program Analyst (LPA) T. White conducted case management visit regarding incident that was submitted to CCLD on 06/14/2021. LPA contacted Administrator for COVID assessment prior to today's visit via telephone call. LPA spoke with Administrator, Lilibeth Meza and explained the purpose of the visit.

Based on photos received on 06/14/2021, LPA observed Resident #1 (R1) has multiple toe nails on both feet that been neglected. On 06/17/2021, LPA observed Staff #1 (S1) measured R1's toenails. Based on observation, R1's big toe on the right side was measured at about 2 centimeters. R1's big toe on the left side was measured at about 1.75 centimeters.

Based on interview, S1 stated R1 has an appointment scheduled on June 22, 2021.

The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in civil penalties.



Exit interview conducted with Administrator. A copy of report and appeal rights given.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana WhiteTELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 II ASSISTED LIVING FACILITY
FACILITY NUMBER: 342700662
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/17/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/22/2021
Section Cited

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87468.1(a)(16): Personal Rights...:(a)Residents in all residential care facilities for the elderly shall ...(16)To receive or reject medical care or other services.
This requirement was not met as evidence by
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Based on LPA observation, Licensee did not comply with the section cited above in 87468.1(a)(16). LPA observed multiple toe nails on R1 left and right foot neglected, which poses an immediate health and safety risks 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: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana WhiteTELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2021
LIC809 (FAS) - (06/04)
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