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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700662
Report Date: 06/30/2023
Date Signed: 06/30/2023 07:05:12 PM


Document Has Been Signed on 06/30/2023 07:05 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
SACRAMENTO AC/SC, 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:
06/30/2023
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:LILIBETH MEZATIME COMPLETED:
07:30 PM
NARRATIVE
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On 6/30/2023 at 2:15pm, Licensing Program Analyst (LPA) Jennifer Fain and Licensing Program Manager (LPM) Liza King arrived at this facility unannounced to conduct an annual inspection visit. LPAs met with the Administrator Lilibeth Meza and explained the purpose of the visit.

LPA Fain and LPM King inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common TV area, and outside of the facility to ensure compliance with Title 22 regulations. Facility is an RCFE facility with a current census of 6. Facility has 5 bedrooms and 2 bathrooms for resident use. Bathroom 2 is part or room 1 which accommodates 2 residents. Facility currently provides care for 2 ambulatory residents, 4 non ambulatory residents, none of which are bedridden.

Water temperature reads 112.6 which is within the regulated temperature of 105*F to 120*F in the bathroom and room temperature reads 76 degrees Fahrenheit. LPAs observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were sanitary and furnished. Fire extinguisher was serviced 9/4/2022 and is in compliance.

Garden Area was observed to have broken and collapsing boards, broken lighting, broken benches, Broken planters, broken statuary, bags of recycling, and debris. Pathway was observed to have uneven and missing pavers. Hose was observed in pathway creating tripping hazard.

Gates to both sides of house are in need of repair.

Laundry room was unlocked and Toxins were observed in unlocked cabinets and on the floor.

3 cans of food was observed to be expired. TA was provided and a reinspection will occur.


SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Jennifer FainTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 06/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2023
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
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: HOME SWEET HOME II ASSISTED LIVING FACILITY
FACILITY NUMBER: 342700662
VISIT DATE: 06/30/2023
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Room 1 bathroom was observed to have personal care items unlocked and obvious urine on the floor. Knobs were observed to be missing and hanging loose on cabinets and closet.

Room 4 was observed to have a light switch in the closet out of reach of resident. In addition, upon interview with the licensee this resident requires 2 persons to get our of bed and at times the facility is unable to provide this assistance due to the hoyer sling being wet from a shower. Upon reinspection the licensee agreed to purchase a second sling and include this ADL assistance on the residents care plan and an accessible lamp or assistive device so that the resident is able to turn on and off their light. TA was given and reinspection will occur.

Bathroom 2 was observed to have soap and sanitizer unlocked and trash cans without lids.

Kitchen stove was observed to have 2 of 4 burners nonfunctional. The licensee reported that a new stove has already been purchased and will be observed at reinspection.

Refrigerator was observed to have expired food and unlocked medications and containers of food without dates.

The activities room was observed to be used as a staff space. The licensee agreed to submit an updated LIC200, and facility sketch to request a Fire Department inspection for this area to be turned into a staff area prior to reinspection. From todays date to the fire inspection licensee agreed to use this area as the intended purpose. Facility backyard had a large structure that was locked and inaccessible Licensee agreed to obtain keys and keep on premises to provide LPA access at next inspection.

The annual inspection was not completed today due to time constraints, the Department will return at a later date for a Annual continuation.

Deficiencies are being cited from the Health and Safety Code (HSC). Failure to correct deficiencies may result in the assessment of civil penalties.

Exit interview was held and a report and appeal rights were given to Administrator.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Jennifer FainTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 06/30/2023 07:05 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
SACRAMENTO AC/SC, 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: 06/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/21/2023
Section Cited
CCR
87303(a)

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(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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Licensee will notify LPA when all debris has been removed and a reinspection will occur.
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This was not met as evidenced by garbage and debris in the backyard. 2 gates in the backyard that require repair. Bathroom floor saturated in urine. Knobs on cabinets and closet missing or hanging loose. Carpet worn and in need of cleaning.
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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: Jennifer FainTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 06/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2023
LIC809 (FAS) - (06/04)
Page: 5 of 5


Document Has Been Signed on 06/30/2023 07:05 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
SACRAMENTO AC/SC, 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: 06/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/30/2023
Section Cited
CCR
87705(f)(2)

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(f) The following shall be stored inaccessible to residents with dementia:
(2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
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Licensee removed all toxins from resident areas during the inspection.
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This was not met as evidenced by LPA observed personal care items in bathrooms, window sills, and in unlocked cabinets in the laundry, PRN medication was observed in pantry drawers and residents dressers. Insulin pen was observed unsecured in refridgerator. This is an immediate risk to the health and safety of residents in care.
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Type A
07/03/2023
Section Cited
CCR87716(a)

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(a) As specified in Section 87209, Program Flexibility, the licensee may submit a written exception request if he/she agrees that the resident has a prohibited and/or restrictive health condition but believes that the intent of the law can be met through alternative means.
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The Licensee will submit an exception request to LPA Jennifer.Fain @dss.ca.gov
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This was not met as evidences by one resident who presented with a catheter and whom is unable to care for it themseves per the licensee during the inspection. TA was provided. This presents an immediate threat to the resident 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: Jennifer FainTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 06/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 06/30/2023 07:05 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
SACRAMENTO AC/SC, 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: 06/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/03/2023
Section Cited
CCR
87459(a)

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(a) 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..
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The licensee will submit personalized updated Needs and Servic Plans for the 2 residents dicussed during todays visit to Jennifer.Fain@dss.ca.gov
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This was not met as evidenced by: During file review and interview ith staff and the licensee 2/2 residents needs and services plan did not address their need for 2 person or hoyer tranfser assist, or assistance with glucose monitoring. This poses an imediate risk to the health and safety of the resident.
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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: Jennifer FainTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 06/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2023
LIC809 (FAS) - (06/04)
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