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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700662
Report Date: 08/03/2021
Date Signed: 08/03/2021 04:43:05 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:HOME SWEET HOME II ASSISTED LIVING FACILITYFACILITY NUMBER:
342700662
ADMINISTRATOR:MEZA, LILIBETHFACILITY TYPE:
740
ADDRESS:8781 KELSEY DRIVETELEPHONE:
(916) 661-2940
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:6CENSUS: 5DATE:
08/03/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:55 PM
MET WITH:Lilibeth MezaTIME COMPLETED:
04:41 PM
NARRATIVE
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On 8/3/21 at 2:50pm, LPA Michael Bilger arrived at this facility unannounced to conduct an annual inspection visit. LPA met with the administrator Lilibeth Meza and explained the purpose of the visit.

LPA Bilger 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 backyard of the facility to ensure compliance with Title 22 regulations. Facility is a 6 bed facility with a current census of 5. Facility has 6 bedrooms 4 bedrooms for residents. 1 bedroom is for staff. LPA also conducted the infection control domain tool.
The facility submitted a LIC 808 mitigation plan, which was approved. The facility has central entry point and has implemented screening and sign in procedures at the front door area. The facility conducts routine symptom screening for employees, residents, and visitors. LPA observed the facility to have hand washing, COVID - 19 informational, and social distancing signs posted throughout the facility, on the front door, and back yard. The facility has a designated infection control lead. The facility is able to designate and dedicated a Covid-19 room/bathroom if needed. Common touch surfaces are cleaned after each use.

Water temperature reads 110.3*F in the bathroom and room temperature reads 77*F. LPA observed the facility to have adequate food supply. Resident rooms were clean and sanitary . The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguisher was checked 9/1/2020. Facility has an emergency food and water kit.

Per California Code of Regulations, Title 22, deficiencies were observed during this visit. Exit interview was held and a report along with appeal rights was given to Administrator Lilibeth Meza.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2021
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
CCLD Regional Office, 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: 08/03/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(3)
87608 Postural Supports (3) A written order from a physician indicating the need for postural support shall be maintained in the resident record...

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not ensure a physician's order for Resident1 (R1) half bed rails which poses a potential health, safety, and personal rights risk to persons in care.
POC Due Date: 08/13/2021
Plan of Correction
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Licensee will notify physician and obtain order for half bed rail and submit copy of physician's order to LPA by POC due date

Licensee will audit all resident charts to ensure physician orders exist for any postural supports used. Licensee to submit finished written audit to LPA by POC due date
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2021
LIC809 (FAS) - (06/04)
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