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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 02:56:31 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 - IncidentUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Lilibeth Meza, AdministratorTIME COMPLETED:
03:05 PM
NARRATIVE
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On 06/17/2021, Licensing Program Analyst (LPA) T. White conducted case management visit regarding reporting requirements. LPA explained the purpose of the visit with Administrator, Lilibeth Meza.

Based on interview, Resident #1 (R1) was sent to the hospital on 05/24/2021 because R1 was agigated. Staff #1 (S1) stated the Doctor informed facility R1 was COVID positive. Based on interview, S1 did not submit incident report to CCLD. S1 stated she reported incident to the Doctor.

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 B
06/25/2021
Section Cited

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87211(a)(1)(D): Reporting Requirements
(a) Each licensee shall require...(1)A written report shall be submitted to the licensing agency... Any incident which threatens the welfare, safety or health of any resident. This requirement is not met as evidenced by:
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Based on LPA observation, Licensee did not comply with the section cited above in 87211(a)(1)(D). LPA observed facility did not submit incident report to CCLD regarding R1 going to the hospital and testing positive for COVID, which poses a potential 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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