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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700662
Report Date: 02/09/2022
Date Signed: 02/09/2022 10:26:17 AM

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:
02/09/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Lilibeth MezaTIME COMPLETED:
10:00 AM
NARRATIVE
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Licensing Program Analysts (LPA's) Maja Jensen and Bruce Jacobs arrived at this facility unannounced on 02/9/22 at 9:00 AM to conduct a case management visit. LPA's met with Lilibeth Meza and explained the purpose of the visit.

The purpose of the visit is to follow up on an incident report received on 01/31/2022. The report stated on 01/29/2022 at approximately 11 AM, R1 left the facility without telling staff. R1 got a few blocks away when staff noticed he was gone. Staff ran after him and asked him to go back but instead he yelled at staff and did not want to comply. The administrator came and asked him to go back but he did not want to comply so police were called.

Based upon interviews conducted on 02/09/2022 and facility records, R1 is not able to leave the facility unassisted.

The following deficiency was observed and cited from the California Code of Regulations, Title 22, and California Health and Safety Code.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2022
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: 02/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/09/2022
Section Cited

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Medical Assessments:(b) The medical assessment shall include, but not be limited to:....(4) Identification of physical limitations of the person to determine his/her capability to participate in the programs provided by the licensee, including any medically necessary diet limitations. This requirment was not met as evidenced by:
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LIC 602 indicates that R1 is unable to leave facility unassisted. There is no behavioral health issues noted on the physician's report. R1 has left the facility on multiple occassions unassisted to go for a walk around the neighborhood and returned safely. This is a potential safety risk to clients in care.
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In addition the facility administrator will review all LIC 602's to ensure accuracy and will train all staff to follow the directions on the LIC 602 within 30 days.

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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: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2022
LIC809 (FAS) - (06/04)
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