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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 10:24:11 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 - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Lilibeth MezaTIME COMPLETED:
10:40 AM
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Licensing Program Analysts (LPA's) Bruce Jacobs and Maja Jensen arrived at the facility unannounced to conduct a follow up case management visit related to the informal conference on 9/29/21. LPAs were screened at the door for COVID precautions and LPA asked screening question of the staff. LPAs met with Facility Administrator Lilibeth Meza for this visit.

During the informal conference the issues discussed were pressure injuries, urinary tract infections, wound care and reporting requirements. The licensee has submitted the documentation requested during the informal conference to CCLD, including LIC 500, LIC 308, LIC 610D and Designated Administrator information. The licensee has also completed in-service training for wound care. The Technical Service Progam (TSP) is in progress and scheduled to commence tomorrow (2/10/22). The TSP will assist the facility with addressing the remaining issues discussed at the informal conference.

No deficiencies are cited in this report. Exit interview conducted.
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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