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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
342700662
Report Date:
04/12/2024
Date Signed:
04/12/2024 03:55:55 PM
Document Has Been Signed on
04/12/2024 03:55 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:
04/12/2024
TYPE OF VISIT:
Case Management - Health Checks
UNANNOUNCED
TIME BEGAN:
02:00 PM
MET WITH:
Josephina Dayrit
TIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a health and safety check on the residents in care on 4/12/24 at 2pm. LPA met with Caregiver Josephina Dayrit who contacted the Administrator regarding todays visit. Administrator arrived within 15 minutes to assist with todays visit.
LPA observed 5 of 6 residents in the home during this visit. 1 is out in the community. The hot water temper measured at 106.1*F. The inside temp was measured at 73*F on the wall thermometer.
Residents were alert and responsive during this visit.
The 2 day perishables and 7 day non perishables were observed during this visit.
Files for all residents were reviewed. LPA observed the centrally stored medications area to be locked and inaccessible to residents.
A copy of the current Liability Insurance was received. During the visit the last resident arrived ambulatory and responsive.
There were 2 caregivers present during this visit.
During the visit Administrator needed to leave and requested caregiver sign todays report.
LPA did not observe any hazards or lack of care and supervision during this visit.
SUPERVISOR'S NAME:
Stephen Richardson
TELEPHONE:
(916) 263-4746
LICENSING EVALUATOR NAME:
Victoria Brown
TELEPHONE:
(209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE:
04/12/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/12/2024
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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