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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700662
Report Date: 02/24/2022
Date Signed: 02/24/2022 03:03:07 PM


Document Has Been Signed on 02/24/2022 03:03 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
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: 6DATE:
02/24/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Licensee, Lilibeth MezaTIME COMPLETED:
03:10 PM
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Licensing Program Analyst (LPA) T. White conducted a case management inspection of Home Sweet Home 2 Assisted Living. LPA met with Licensee, Lilibeth Meza to ensure the facility is in compliance with applicable statutes and regulations. LPA confirmed with staff there are zero residents or staff that have displayed any signs or symptoms of COVID-19 in the last 10 days.

During the visit, the LPA conducted interviews with 1 staff. Based on interviews, staff are paid bi-weekly, never receive a late pay check, and lunch breaks while on shift. There is 1 live- in care staff.

LPA reviewed staff/resident files and resident medications and observed all necessary documents in the file. LPA reviewed LIC 500 and staff schedule.

LPA conducted a tour of the physical plant and observed 4 residents and 2 staff members present in the facility. LPA observed proper signage regarding COVID-19, California Minimum Wage Notice, and Emergency Disaster Plan.

Based on interviews, file/medication reviews, and observation of the physical plant, it appears the facility is in compliance with applicable statutes and regulations. An exit interview was held with Licensee and a copy of the report was provided.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana WhiteTELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2022
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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