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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700662
Report Date: 06/02/2022
Date Signed: 06/02/2022 01:55:08 PM


Document Has Been Signed on 06/02/2022 01:55 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:
06/02/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Jonalyn Gayao, CaregiverTIME COMPLETED:
02:10 PM
NARRATIVE
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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 Caregiver, Jonalyn Gayao 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.

LPA conducted a tour of the physical plant and observed 4 residents and 2 staff members present in the facility. LPA reviewed staff/resident files and resident medications and observed all necessary documents in the file. LPA reviewed LIC 500 and staff schedule.

On 06/02/2022 at 12:50pm, LPA reviewed Resident #1 (R1) Medication Administration Records (MARs) Log. Based on MARs, R1's Trazadone should be administered at 8pm. Based on record review, Staff #1 (S1) signed R1's MARs in the afternoon. LPA observed the time is incorrect. Based on interview with Staff #2 (S2), S1 made a "mistake".

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 was held with Caregiver. 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: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2022
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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Document Has Been Signed on 06/02/2022 01:55 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
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: 06/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/03/2022
Section Cited

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87465(c)(2): Incidental Medical and Dental Care: (c) If the resident's physician has stated in writing...(2)Once ordered by the physician the medication is given according to the physician's directions.

This requirement was not met as evidence by:
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Based on documentation, licensee did not comply with the section cited above in 87465(c)(2). Based on observation, S2 signed R1's prescription medication in the afternoon which is prescribed in the evening. 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: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana WhiteTELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2022
LIC809 (FAS) - (06/04)
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