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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700662
Report Date: 09/01/2022
Date Signed: 09/01/2022 10:44:42 AM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/13/2022 and conducted by Evaluator Renee Campbell
COMPLAINT CONTROL NUMBER: 27-AS-20220713080906
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:
09/01/2022
UNANNOUNCEDTIME BEGAN:
10:29 AM
MET WITH:Lilibeth MezaTIME COMPLETED:
11:00 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Questionable Death
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 9-1-22 at 10:30 am, LPAs Michael Bilger and Renee Campbell arrived unannounced to deliver complaint findings for the allegation noted above. LPAs met with Lilibeth Meza, Licensee and explained the purpose of the visit. Based on Department record review it was determined that resident1 (R1) was sent to the hospital from board and care facility on 3/24/21, transferred to a skilled nursing facility, and never returned to the board and care facility. It was further determined that R1 passed away on 9/28/21; R1 did not pass away at board and care facility. Based on Departments record review, it is determined that this allegation is UNFOUNDED. An exit interview was conducted with Lilibeth Meza and a copy of this report was left with licensee.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: 916-206-6380
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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