342700662-7-14-2022-27-AS-CVAO-CGBUF8-20220714153220

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700662
Report Date: 07/14/2022
Date Signed: 07/14/2022 03:33:00 PM

Document Has Been Signed on 07/14/2022 03:33 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 FACILITY		FACILITY NUMBER:	342700662
ADMINISTRATOR:	MEZA, LILIBETH		FACILITY TYPE:	740
ADDRESS:	8781 KELSEY DRIVE		TELEPHONE:	(916) 661-2940
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95624
CAPACITY:	6	CENSUS: 6	DATE:	07/14/2022
TYPE OF VISIT:	Case Management - Legal/Non-compliance	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Lilibeth Meza		TIME COMPLETED:	10:45 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	A Non-Compliance Conference was conducted today via Microsoft Teams with the Sacramento South Regional Office. The purpose of this Non-Compliance Conference meeting is to discuss the inability to remain in substantial compliance with the regulations/or specific incident that has occurred in the last 16 months. Present in the meeting is Acting Regional Manager (RM) Liza King, Licensing Program Manager (LPM) Stephen Richardson, Licensing Program Analyst (LPA) Treana White, Licensing Program Analyst (LPA) Christina Valerio, Licensing Program Analyst (LPA) Renee Campbell, and Licensee Lilibeth Meza and Administrator Eric Serrano The Non-Compliance Conference process was explained during this meeting. A Non-Compliance Conference Summary (LIC 9111) was generated to document this office meeting. A copy of this report and the LIC 9111 was provided to the licensee. Home Sweet Home II – Assisted Living Facility has been cited for 5 Type A and 3 Type B violations The facility participated the in Technical Support Program, which had 5 engagement visits dated from 02/10/22 to 03/22/22. The Department has issued citations and civil penalties in the areas of: Care and Supervision, Personnel Requirements, Basic Services, Fire Clearance, Personal Rights

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022

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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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
	VISIT DATE: 07/14/2022

NARRATIVE

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Issues discussed during the meeting were:
· Repeat violations and civil penalties.
· Technical Support Program Recommendations
· Care and Supervision
· Reporting Requirements
· Record Keeping/Personnel Requirements
· Fire Clearance
· Personal Rights
· Review of Licensee's Plan to maintain compliance

The facility has stated they will do the following to achieve continued and substantial compliance:
· Create a reminder system of when documents (Appraisal Needs and Service Plan, Physicians Report) need to be updated. Licensee to send copy of reminder system to the Regional Office (RO) by 08/01/2022.
· Create a reminder system of when documents (Staff Personnel Records, Training, Facility Annual Forms) need to be updated. Licensee to send a copy of reminder system to the RO by 08/01/2022
· Monitor and reassess resident needs and services on a regular basis, update care plans annually and when there is a change in condition
· Ensure staff meet the needs of the residents in care as determined by the needs and services as documented on file
· Ensure Administrator is on-site for a minimum of 20 hours per week. Licensee to send updated LIC 500 to reflect days and times of when Administrator will be on site for each facility licensed by Lilibeth Meza
· Utilize TSP Medication Guide on staff training. Licensee to send sign in sheet of in-service training to RO by 08/01/2022
· Review the Reporting Requirements regulation (87211) well with facility staff. Licensee to send sign in sheet of in-service training to RO by 08/01/2022
· Conduct regular self-audits and assessments using checklists and the CARE tool to maintain compliance in all areas of the operation of the facility. Licensee to send proof of accessing the RCFE CARE tool by 08/01/2022

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022

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
	VISIT DATE: 07/14/2022

NARRATIVE

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CCLD will do the following:
· Continue Increase monitoring
· Review reports monthly for compliance

The facility was advised that completing a Non-Compliance Conference does not deprive the Department of its authority to take appropriate formal legal action under the Health and Safety Code if such action is deemed necessary by the Regional Manager. At this time, the Department will re-evaluate compliance in 6-9 months before referring this case to Legal for Administrative Action.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited during this visit. An exit interview was conducted with Licensee Lilibeth Meza via Microsoft Teams and a copy of this report was provided via email and an electronic email read receipt confirms receiving these documents. Licensee to send a signed copy of the report via fax (916) 263-4744.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022

LIC809 (FAS) - (06/04)

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