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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700662
Report Date: 11/03/2021
Date Signed: 11/03/2021 11:12:25 AM

Document Has Been Signed on 11/03/2021 11:12 AM - It Cannot Be Edited

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: 6DATE:
11/03/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Lilibeth Meza and Eric SerranoTIME COMPLETED:
11:30 AM
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On 11/3/21, Licensing Program Analyst (LPA), Mohamed Filouane, conducted an unannounced 1-year required infection control inspection. At approximately 10:10 AM, LPA met with a staff member and explained the purpose of the visit. LPA was sanitized following the facility's entrance health and safety procedures. LPA also had his temperature checked and logged and then signed into the facility. LPA spoke with the Administrator over the phone and explained the purpose of the visit.

On 10:20 AM, Administrator Lilibeth Meza and Assistant Administrator Eric Serrano arrived at the facility. LPA verbally reviewed the status of the client 1 (C1) in regards to this health and safety visit. LPA confirmed that on 10/27/21, the facility had sent C1 to the hospital. C1 returned to the facility on the same day, 10/27/21. C1 was assessed by a nurse at the hospital, then a doctor from the hospital stated to the Administrator that the wound was a stage two injury. The doctor had authorized the discharge of client 1 back to the facility on 10/27/21. LPA requested the discharge paperwork of client 1.

LPA observed client 1 sitting in a wheelchair outside the facility. The client greeted LPA as LPA entered the facility. Administrator and Assistant Administrator stated the client is doing well and healthy.

No deficiencies were cited today. Exit interview conducted with Administrator. A copy of this report will be given to the facility.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Mohamed Filouane
LICENSING EVALUATOR SIGNATURE: DATE: 11/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/03/2021
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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