342700662-8-11-2021-27-AS-LKIG-C628T8-20210818224732

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700662
Report Date: 06/17/2021
Date Signed: 08/11/2021 01:56:37 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/15/2021 and conducted by Evaluator Treana White

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20210615115007

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:	06/17/2021
		UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Lilibeth Meza, Administrator		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Unlawful Eviction

INVESTIGATION FINDINGS:

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On 08/11/2021, Licensing Program Analyst (LPA) T. White conducted an unannounced complaint investigation regarding the above allegation. LPA contacted Administrator for COVID assessment prior to today's visit via telephone call. LPA White discussed the purpose of the visit and the elements of the allegation with Administrator, Lilibeth Meza.

During the course of investigation, LPA collected Resident #1 (R1) Admission Agreement, Medication Administration Records (MARs), Resident Roster, and Discharge/Hospitalization Papers. Based on interview, R1 was sent to the hospital because R1 was agitated. Staff #1 (S1) stated the Doctor informed facility R1 was COVID positive. S1 requested for R1 to stay at the hospital until the next morning to prepare R1's room. S1 stated the facility needed to prepare bed, complete sanitation, and follow COVID protocols for 14 day isolation. S1 stated the Doctor requested R1 to stay at the hospital due to R1's a decrease in oxygen level.S1 was ensuring the health and safety of staff and residents by placing R1 in a private room. Based on admission agreement, R1 has a shared bedroom. Based on interview, S1 stated the facility did not issue an eviction.
Report continues on 9099C.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana White	TELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2021

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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Control Number 27-AS-20210615115007

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 06/17/2021

NARRATIVE

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Based on interview with Family Member #1 (FM1), R1 did not receive a written statement or a verbal notice from the facility. FM1 stated the facility did not evict R1 during the hospital stay. LPA observed R1's belongings are still at the facility. Based on documentation and observation, there was no documentation that was presented to resident or family member confirming there was an unlawful eviction.

This agency has investigated the complaint alleging unlawful eviction. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. No deficiencies cited during visit.

Exit interview conducted with Administrator and a copy of report given.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana White	TELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2021

LIC9099 (FAS) - (06/04)

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