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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700662
Report Date: 06/02/2023
Date Signed: 06/02/2023 06:44:43 PM


Document Has Been Signed on 06/02/2023 06:44 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:
06/02/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:LILIBETH MEZATIME COMPLETED:
07:00 PM
NARRATIVE
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On 6/2/23 at approximately 3:30 Licensing Program Analyst Maja Jensen and Jennifer Fain arrived at facility unannounced to conduct a case management for health and Safety checks. LPAs Jensen and Fain met with Licensee Lilibeth Meza and explained the purpose of today's visit.

At the time of arrival, there were two staff members present. Staff 2 was determined to be missing an association to the facility based on a review of Guardian.

LPAs Jensen and Fain observed 6 of 6 clients and interviewed 3 of 6 clients. LPA Jensen reviewed 2 resident files. Based on observation, a review of the resident file and an interview with the Licensee, Resident 4 uses an indwelling urinary catheter. The Licensee advises that home health comes to the facility and changes the catheter weekly. LPA Jensen reviewed R4's Needs and Service Plan and there is no indication on the plan that the resident uses a catheter or who has responsibility for care and monitoring related to this health matter. LPA Jensen also observed records from Home Health that indicate R4 had a diagnosis of severe sepsis with septic shock on 4/6/23 and was hospitalized on or around 3/28/23. The Licensee was unable to provide an incident report for this hospitalization but did provide an incident report for R4 being sent to the hospital for stomach pain on 4/8/23.

LPA Fain reviewed the resident file for R1 and the Medication Administration Record (MAR) for R1. R1 requires medication for diabetes by injection. R1 and the Licensee confirmed that R1 administers her own injections. The LIC 602 (Physician's Report) dated 4/28/23 indicates that the resident is unable to administer their own injections and unable to perform her own glucose testing. LPA Jensen interviewed the Licensee who stated she believes the physician made an error or needs an update on the LIC 602.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


Document Has Been Signed on 06/02/2023 06:44 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: 06/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/02/2023
Section Cited
CCR
87628(a)

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Diabetes
The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by an appropriately skilled professional. This requirement was not met as evidenced by:
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The Licensee arranged to have a licensed professional administer the insulin for the next dose and will send an attestation to jennifer.fain@dss.ca.gov that a licensed professional will continue to administer the insulin and conduct glucose testing until and unless the LIC 602 is changed.
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Based on LPA Jensen's review of the R1's resident file and MAR and based on interviews with the licensee, R1 has been administering their own insulin in contradiction of the LIC 602. This poses an immediate risk to the health, safety and personal rights of residents in care.
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Type A
06/03/2023
Section Cited
CCR87459(a)(7)(F)

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Functional Capabilities
The facility shall assess the person's need for personal assistance and care by determining his/her ability to perform specified activities of daily living. Such activities shall include, but not be limited to:
...Physical condition, including:
...Medical history and problems. This requirement was not met as evidenced by:
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The Licensee agrees to update the Needs and Service Plan by 6/3/23 and will have all care providers sign an attestation they have reviewed the addendum. Proof of Plan of Correction completion will be emailed to Jennifer.Fain.
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Based on LPA Jensen's review of R4's Needs and Service Plan and medical records review, catheter care and infection control was not addressed and R4 suffered from severe sepsis "likely from UTI" in April of 2023. This poses an immediate risk to the health, safety and personal rights of 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: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4


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: 06/02/2023
NARRATIVE
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Deficiencies are being cited from the California Code of Regulations (CCR) Title 22. Civil Penalties are also being assessed for Caregiver Background Check.

An exit interview was conducted, a copy of this report, an LIC 811 and appeal rights were given.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 06/02/2023 06:44 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: 06/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/03/2023
Section Cited
CCR
87411(g)

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Personnel Requirements - General
Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall:
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Request a transfer of a criminal record clearance as specified in Section 87355(c). This requirement was not met as evidenced by:
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The Licensee emailed a transfer request for S2 and sent a copy of the email to LPA Fain at jennifer.fain@dss.ca.gov during the course of the visit. No further Plan of Correction is needed at this time
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Based on LPA Jensen's review of guardian a staff member present in the facility at the time of the visit was not associated to the facility as verified through Guardian. This poses an immediate risk to the health safety and personal rights of residents in care.
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Type B
06/09/2023
Section Cited
CCR87211(a)(1)(D)

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Reporting Requirements
A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. ...
Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.
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The Licensee agrees to email an attestation to jennifer.fain@dss.ca.gov that this regulation has been read, understood and will be complied with by POC due date.
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This requirement was not met as evidenced by LPA Jensen's records review showing R4 was hospitalized and the hospitalization was not reported. This poses a potential risk to the health, safety and personal rights of 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: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4