342700662-3-7-2024-27-AS-KHOS-D3PNQT-20240325104029

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700662
Report Date: 03/07/2024
Date Signed: 03/07/2024 03:46:13 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/29/2024 and conducted by Evaluator Victoria Brown

COMPLAINT CONTROL NUMBER: 27-AS-20240229110447

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: 5	DATE:	03/07/2024
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Lilibeth Meza		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff did not supervise resident resulting in resident wandering away from facility.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a complaint investigation of the above-mentioned allegation on 3/7/24 at 1:30pm. LPA met with Eric Serrano, Caregiver and Administrator Lilibeth Meza and stated the purpose of the visit. LPA conducted interviews of Staff #1 (S1), (S2), Resident #1 (R1) and Administrator. R1 stated a fall occurred but not in the street and alcohol was not a factor that day.

Based on interviews and a review of R1's most recent Physician Report (LIC602) dated 2/23/24, which indicates R1 is able to leave the facility unassisted, does not have a diagnosis of dementia nor Mild Cognitive Impairment.
"The allegation is UNFOUNDED, meaning that the allegation was false, could not have happened and/or was without a reasonable basis. This Department has therefore dismissed the complaint."
Per California Code of Regulations, no deficiencies were observed or cited. Exit interview held, and a copy provided.

Unfounded

Estimated Days of Completion: 30

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024

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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