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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701444
Report Date: 08/12/2024
Date Signed: 08/12/2024 03:44:22 PM


Document Has Been Signed on 08/12/2024 03:44 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:PADUA, NICHOLASFACILITY TYPE:
740
ADDRESS:3391 JOLA CIRCLETELEPHONE:
(916) 661-2940
CITY:SACRAMENTOSTATE: CAZIP CODE:
95832
CAPACITY:6CENSUS: 6DATE:
08/12/2024
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Lilibeth MezaTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to the facility to conduct a post-licensing inspection. LPA Valerio met with facility staff, and explained the purpose of the visit. LPA was later met by Licensee Lilibeth Meza.

LPA Valerio and facility staff toured the facility to ensure compliance with Title 22 regulations. LPA observed 3 staff on shift. LPA Valerio observed resident bedrooms. Resident bedrooms were observed to be free from odors and fully furnished. Resident bathrooms were clean and stocked with paper towels, hand soap, toilet paper, skid mat, and trash can. Common areas were observed to be fully furnished. Residents were observed watching television, taking a nap in their room, and enjoying the weather in the backyard. Staff were observed cleaning up after meal times, preparing meals, assisting residents with requested needs. The temperature inside the facility was at a comfortable temperature. The facility was observed to have an adequate supply of food in addition to an emergency supply of food. Sharps, cleaning supplies, and medications were locked up and inaccessible to residents in care. LPA observed the backyard. There were two sheds outside. One shed is being utilized for a staff room and the other shed is being utilized for storage. LPA reviewed facility files, including the facility sketch and fire clearance. The facility was cleared to have the shed in the backyard for a staff room. No emergency exits were obstructed.

LPA Valerio reviewed three (3) resident files. Resident files were observed to be complete with required annual documentation. LPA reviewed two (2) staff files. Staff files were current with required training.

Per California Code of Regulations (CCR) - Title 22, no deficiencies are being cited. An exit interview was held with Licensee Lilibeth Meza, and a copy of the report was provided.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 08/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2024
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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