342700662-12-6-2023-27-AS-VBRN-CY9RQJ-20231206121338

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700662
Report Date: 12/06/2023
Date Signed: 12/06/2023 12:13:50 PM

Document Has Been Signed on 12/06/2023 12:13 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

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:	12/06/2023
TYPE OF VISIT:	Case Management - Legal/Non-compliance	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Lilibeth Meza		TIME COMPLETED:	12:30 PM

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	Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Case Management - Legal/Non-compliance visit on 12/6/23 at 9am. LPA met with Lilibeth Meza, Administrator and stated the purpose of the visit. LPA reviewed the following subject areas that were contained in the Non-Compliance Conference held on 7/12/2022. · Create a reminder system of when documents (Staff Personnel Records, Training, Facility Annual Forms, Appraisal Needs and Service Plan, Physicians Report) need to be updated. -Administrator created a calendar to remind staff when documents and appointments are needed · Monitor and reassess resident needs and services on a regular basis, update care plans annually and when there is a change in condition -Last documented assessment for Resident #1 (R1) was July 31, 2023 · Ensure staff meet the needs of the residents in care as determined by the needs and services as documented on file -Administrator observes staff and communicates with residents on a daily basis regarding care and behaviors · Ensure Administrator is on-site for a minimum of 20 hours per week. -Administrator provided the LIC500 indicating dates and time allotted in the facility. · Utilize TSP Medication Guide on staff training. -Last documented in-service training for medication was September 10, 2023 · Review the Reporting Requirements regulation (87211) well with facility staff. -Last documented in-service training was October 8, 2023 · Conduct regular self-audits and assessments using checklists and the CARE tool to maintain compliance in all areas of the operation of the facility. -Administrator created a checklist which includes dates of when the documents were updated. There is also a calendar that will be used for all updates for staff and residents.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023

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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: HOME SWEET HOME II ASSISTED LIVING FACILITY	FACILITY NUMBER: 342700662
	VISIT DATE: 12/06/2023

NARRATIVE

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LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed 2-day perishables and 7-day non-perishables.

The temperature inside the facility was observed to be at 71*F which is within the required range of 68-85*F. The hot water temperature was measured at 107.6*F which is within the required range of 105-120*F. LPA observed fire extinguisher(s), smoke and carbon monoxide detectors, and central heating and air in the facility. LPA reviewed Guardian process during this visit. LPA requested an update on the completion of the work needed to the skyline. Administrator contacted Property owner and is awaiting a response. The last emergency drill was conducted 11/22/23.

LPA observed the centrally stored medications area to be locked and inaccessible to residents.

The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide.

LPA reviewed 2 staff and 2 resident files during this visit.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies cited.
Exit interview held, copy of report given

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023

LIC809 (FAS) - (06/04)

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