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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700662
Report Date: 12/13/2022
Date Signed: 12/13/2022 04:53:40 PM


Document Has Been Signed on 12/13/2022 04:53 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:JONALYN GAYAOFACILITY TYPE:
740
ADDRESS:8781 KELSEY DRIVETELEPHONE:
(916) 661-2940
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:6CENSUS: 6DATE:
12/13/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Lilibeth MezaTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Renee Campbell conducted a case management inspection of Home Sweet Home Assisted Living. LPA met 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.

LPA conducted a tour of the physical plant and observed 6 residents and 2 staff members present in the facility. LPA reviewed
· Review reminder system of when documents (Appraisal Needs and Service Plan, Physicians Report) need to be updated, SYSTEM UP TO DATE
· a reminder system of when documents (Staff Personnel Records, Training, Facility Annual Forms) need to be updated, SYSTEM UP TO DATE
· ** Random review of 2 of 2 resident files to ensure
o needs and services were updated on a regular basis,
o care plans were updated annually. Monthly care plan updated and to be added to checklist.
o medications administered as ordered .
· LPA reviewed current LIC 500 and/or staff schedule to ensure Admin was present 20 hours a week met
· Reviewed staff training conducted since Aug to include dementia training.
· **Reviewed incident reports and death reports - Facility has reported incidents timely.
· Facility has self-audits and assessments using checklists and the CARE tool to maintain compliance in all areas of the operation of the facility.
Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited during this visit.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: 916-206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2022
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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