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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701444
Report Date: 05/14/2024
Date Signed: 05/14/2024 04:20:54 PM


Document Has Been Signed on 05/14/2024 04:20 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:HOME SWEET HOME II ASSISTED LIVING FACILITYFACILITY NUMBER:
342701444
ADMINISTRATOR:MEZA, LILIBETHFACILITY TYPE:
740
ADDRESS:3391 JOLA CIRCLETELEPHONE:
(916) 661-2940
CITY:SACRAMENTOSTATE: CAZIP CODE:
95832
CAPACITY:6CENSUS: 0DATE:
05/14/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Lilibeth MezaTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Victoria Brown arrived announced on 5/14/24 at 2:30pm and met with Applicant Lilibeth Meza and stated the purpose of the visit. This visit is to conduct a Pre-Licensing Inspection. LPA was allowed entry into the facility that will be licensed and fire cleared for a capacity of 6 non-ambulatory residents. Fire cleared for rooms 3, 4 maybe double rooms. Hospice waiver approved for 3. LPA observed that the facility has submitted a Infection Control Plan.

LPA and Lilibeth Meza toured and inspected the physical plant inside and outside to ensure there are no health and safety concerns. LPA observed the kitchen area, dining area, bedrooms, bathroom, storage areas, back yard and laundry rooms. LPA observed knives/sharps area to be locked. LPA observed required furniture, and lighting throughout the facility. The hot water temperature measured at 75 *F which is within the required range of 105-120*F. The temperature inside the facility measured at 118 *F which is within the required range of 68-85*F. Residents are not present during this visit as the relocation should be as of June 1st due to lease not being renewed by Property owner. LPA observed refrigerator and cabinets that will contain supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days. The first aid kit will include supplies such as sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. LPA observed area for centrally stored medications to be locked. LPA observed the fire extinguisher(s), smoke and carbon monoxide detector(s) and exit alarms on doors in the home. Facility has central heating and air. LPA observed the area where the staff and resident files will be made readily available for review.

Component III conducted - There are no objections to licensure at this time. -Licensure pending.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no violations cited during this visit. An exit interview was conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2024
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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