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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
342700662
Report Date:
07/28/2023
Date Signed:
08/07/2023 01:31:40 PM
Document Has Been Signed on
08/07/2023 01:31 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 FACILITY
FACILITY NUMBER:
342700662
ADMINISTRATOR:
JONALYN GAYAO
FACILITY TYPE:
740
ADDRESS:
8781 KELSEY DRIVE
TELEPHONE:
(916) 661-2940
CITY:
ELK GROVE
STATE:
CA
ZIP CODE:
95624
CAPACITY:
6
CENSUS:
6
DATE:
07/28/2023
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
08:30 AM
MET WITH:
Jonalyn Gayao
TIME COMPLETED:
06:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jennifer Fain and Licensing Program Manager (LPM) Liza King arrived at this facility unannounced to conduct a continuation to the annual inspection conducted on 06/30/20 23. The purpose of the visit to day was to follow up on concerns from the previous visit, review staff and resident files, medication administration records, the facility plan of operation, emergency plans and procedures as well completed the inspection tool and monitored to the facilities Noncompliance plan. LPAs met with the Administrator Jonalyn Gayao and explained the purpose of the visit. The licensee Lilibeth was contacted via phone throughout the visit to clarify questions and requests by licensing staff and the Admin.
Per the NCC the facility:
·
Has updated Appraisal Needs and Service Plan, Physicians Report
·
Is out of compliance for annual staff training last completed 2021 copies taken.
·
Is documenting that they are conducting regular self-audits and assessments using checklists and the CARE tool to maintain compliance in all areas of the operation of the facility.
During facility observations today and similar to observations on 06/30/2023, cleaning solutions were located in an unlocked cabinet in the residents bathroom, and were removed upon discovery, dried urine was on the floor in a residents bathroom, bedroom light was inaccessible to resident in care, boards on patio are still in need of repair. These items are being cited during todays visit. All other items from the 06/30/23 visit have been addressed.
Staff files: During review of 3/4 staff files, annual training was not up to date for caregiver specific topics and annual medication administration training. No other concerns. LIC 500 did not documents an overnight staff, interview with the Admin reported that the facility does not have awake staff and does not have any residents whom are identified as a wander risk. Resident(s) do have a dementia diagnosis.
Emergency Plan: The facility Emergency / Disaster plan was last updated in 2019 and shall be updated annually. Fire drills although documented as being completed during the facility self audit, staff were unable to recall the last time a drill was performed or the procedure for conducting a fire drill.
SUPERVISOR'S NAME:
Liza King
TELEPHONE:
(916) 263-4752
LICENSING EVALUATOR NAME:
Jennifer Fain
TELEPHONE:
916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE:
07/28/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/28/2023
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
7
Document Has Been Signed on
08/07/2023 01:31 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:
07/28/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the resident bathroom under the sink had cleaning supplies which were removed during the visit.
POC Due Date:
07/28/2023
Plan of Correction
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2
3
4
Cleaning supplies were removed during the visit.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
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2
3
4
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 King
TELEPHONE:
(916) 263-4752
LICENSING EVALUATOR NAME:
Jennifer Fain
TELEPHONE:
916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE:
07/28/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/28/2023
LIC809
(FAS) - (06/04)
Page:
2
of
7
Document Has Been Signed on
08/07/2023 01:31 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:
07/28/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)(1)
Maintenance and Operation
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. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation dried urine was on the batroom floor of a residents private restroom.
POC Due Date:
08/04/2023
Plan of Correction
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Since this an ongoing issue, the licensee will submit a plan of correction by the POC date via email to Jennifer.Fain@dss.ca.gov
Type B
Section Cited
CCR
87303(e)(5)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation one of the residents bathrooms did not contain a nonskid mat. This shower is confirmed to be used by 2 residents.
POC Due Date:
08/04/2023
Plan of Correction
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The licensee will submit a plan of correction by the POC date via email to Jennifer.Fain@dss.ca.gov
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 King
TELEPHONE:
(916) 263-4752
LICENSING EVALUATOR NAME:
Jennifer Fain
TELEPHONE:
916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE:
07/28/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/28/2023
LIC809
(FAS) - (06/04)
Page:
3
of
7
Document Has Been Signed on
08/07/2023 01:31 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:
07/28/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on review of 4 staff files,3/4 annual training was not up to date for caregiver specific topics and annual medication administration training was not current.
POC Due Date:
08/04/2023
Plan of Correction
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The licensee will submit a plan of correction by the POC date via email to Jennifer.Fain@dss.ca.gov
Type B
Section Cited
HSC
1569.69(e)(2)(B)
Other Provisions
(e) Each person who provides employee training under this section shall meet the following education and experience requirements: (2) The person shall meet any of the following practical experience or licensure requirements: (B) Two years of full-time experience, or the equivalent, within the last four years, as an administrator for a residential care facility for the elderly, during which time the individual has acted in substantial compliance with applicable regulations.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Training documented for two new staff hired during 2022 documented the licensee as provideing the onbaosrding required training. The Licennsee has a history of noncomplaince and at the time of training does not meet the above stated requirements due to the noncomplaince concerns.
POC Due Date:
08/04/2023
Plan of Correction
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3
4
The licensee will submit a plan of correction by the POC date via email to Jennifer.Fain@dss.ca.gov
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 King
TELEPHONE:
(916) 263-4752
LICENSING EVALUATOR NAME:
Jennifer Fain
TELEPHONE:
916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE:
07/28/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/28/2023
LIC809
(FAS) - (06/04)
Page:
4
of
7
Document Has Been Signed on
08/07/2023 01:31 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:
07/28/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87219(a)(1)
Planned Activities
(a) Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities. The activities made available shall include: (1) Socialization, achieved through activities such as group discussion and conversation, recreation, arts, crafts, music, and care of pets.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observations conducted on the last three visits to the facility, residents are observed seated in front of the tv. Interview with staff, residents and the Administrator confirmed that no activities are provided..
POC Due Date:
08/04/2023
Plan of Correction
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2
3
4
The licensee will submit a plan of correction by the POC date via email to Jennifer.Fain@dss.ca.gov
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
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 King
TELEPHONE:
(916) 263-4752
LICENSING EVALUATOR NAME:
Jennifer Fain
TELEPHONE:
916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE:
07/28/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/28/2023
LIC809
(FAS) - (06/04)
Page:
5
of
7
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:
07/28/2023
NARRATIVE
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Resident Files: One resident file contained an Admissions Agreement, Needs and Services Plan and Preadmission Appraisal from another facility licensed by the licensee. Upon interview with the Admin it was learned that the resident had transferred from the other facility and documents were not updated TA provided. Three residents are receiving Home Health, the Admin was unable to locate a plan of care or documentation of Home health visits, this was not cited on todays visit, the Admin will fax the Home Health Care Plans to the LPA by 08/04/23, one residents file contained an ATM card and $34 in cash, upon interviewing the Admin it was reported that the facility uses the cash to purchase items for the resident and brings them a receipt. Two receipts were located in the facility file for an ATM purchase of $229 which the Admin reported was the cost of 2 cases of cigarettes that were purchased for the resident the other for $69.23 for 2 cases of soda and chocolates. Follow up will be conducted.
Fire Alarms were tested and in good working order during todays visit, extinguishers were last inspected Sept. 2022, interior, exterior and living quarters were clean and contained the required components. Facility is awaiting an updated fire inspection for an additional staff room in place of the activity room.
LPA was provided an updated copy of LIC 308 and requested an LIC 500 during the visit to document staff present in the building from 7pm to 7am, per the Admin no staff work during these hours, she and two other staff sleep in the staff room. Additional leading questions were provided and Admin reported that if there were an emergency staff would awake and provide assistance. Additional follow up will be conducted.
Per California Code of Regulations, Title 22, deficiencies were observed during this visit and cited on the attached D page. Exit interview was held and a report and appeal rights were given to Administrator Jonalyn Gayao.
SUPERVISOR'S NAME:
Liza King
TELEPHONE:
(916) 263-4752
LICENSING EVALUATOR NAME:
Jennifer Fain
TELEPHONE:
916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE:
07/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/28/2023
LIC809
(FAS) - (06/04)
Page:
6
of
7
Document Has Been Signed on
08/07/2023 01:31 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:
07/28/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87217(a)
A licensee shall not be required to handle residents' cash resources. However, if a resident incapable of handling his own cash resources, as documented by the initial or subsequent appraisal, is accepted for care, his cash resource shall be safeguarded in accordance with the regulations in this section.
This regulation was not met as evidenced by:
This requirement is not met as evidenced by:
Deficient Practice Statement
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4
The licenssee did not ensure that residents cash and ATM card were secured. The residents admissions agreement states that cash in excess of $20 will not be handeled, the licensee does not posess a Surety Bond to handle cash for resdietns and the Facilities Plan of Operation does not support handeling residents cash or monies.
POC Due Date:
08/04/2023
Plan of Correction
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2
3
4
The licensee will submit a plan of correction by the POC date via email to Jennifer.Fain@dss.ca.gov
Type B
Section Cited
CCR
87405(d)(2)
(d) The administrator shall have the qualifications specified in Sections 87405(d).(2) Knowledge of and ability to conform to the applicable laws, rules and regulations.
This requirement is not met as evidenced by:
Deficient Practice Statement
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4
The Administrator of record upon interview was unable to appropriately answer questions pertaining to the requirements and regulations of a RCFE.
POC Due Date:
08/04/2023
Plan of Correction
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4
The licensee will submit a plan of correction by the POC date via email to Jennifer.Fain@dss.ca.gov
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 King
TELEPHONE:
(916) 263-4752
LICENSING EVALUATOR NAME:
Jennifer Fain
TELEPHONE:
916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE:
07/28/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/28/2023
LIC809
(FAS) - (06/04)
Page:
7
of
7