342700662-9-29-2021-27-AS-CVAO-C7BSMG-20210929135956

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700662
Report Date: 09/29/2021
Date Signed: 09/29/2021 02:00:46 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 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:	DATE:	09/29/2021
TYPE OF VISIT:	Office	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Lilibeth Meza		TIME COMPLETED:	11:00 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	An informal conference was conducted today in the Sacramento Regional Office via Microsoft Teams. The purpose of this informal conference meeting is to discuss a substantiated complaint on 08/11/2021 and deficiencies cited during their recent Annual Evaluation conducted on 08/03/2021. Present in the meeting is Home Sweet Home II Assisted Living Licensee Lilibeth Meza, Licensing Program Manager (LPM) Stephen Richardson, LPM Liza King, and Licensing Program Analyst (LPA) Christina Valerio, and LPA Mohamed Filouane. The informal conference process was explained during this meeting. Issues discussed during the meeting were: · Pressure Injuries, Urinary Tract Infections, and Seeking Medical Attention · Reporting Requirements · Wound Care · In-service training for current and new staff *The facility has stated they will do the following to achieve continued and substantial compliance:* · Licensee will send a copy of in-service trainings, including Documentation Practices for On-going Notes, Reporting Requirements, Basic Services, and Residential Care, provided to current and new staff · Licensee will seek an outside agency to provide formal training on Wound Treatment Care and send dates of training with Agency name to LPA Filouane · Licensee will send current facility on-call podiatrist information · Licensee will send current copies of LIC 500, LIC 308, LIC 610D, and Designated Administrator Information for Home Sweet Home – Assisted Living Facility, Home Sweet Home II - Assisted Living Facility, Serrano Guest Home, and Serrano Guest Home #2 · Licensee will report unusual incidents by sending incident reports via fax (916) 263-4744 · Licensee was offered and has agreed to participate in TSP program Continued on LIC 809 - C...

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021

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
	VISIT DATE: 09/29/2021

NARRATIVE

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...Continued from LIC 809

Licensee agrees to send requested documents to LPA Filouane, LPM King, and LPM Richardson by 10/08/21.

At this time, no deficiencies are cited. An exit interview was conducted with all mentioned representatives via Microsoft Teams and a copy of this report will be provided to the facility via email. A copy must be signed and returned to Community Care Licensing (CCL) and the one copy is to be retained by the facility.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021

LIC809 (FAS) - (06/04)

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