342701444-9-3-2024-27-AS-AVIA-D8RSKD-20240903135634

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342701444
Report Date: 09/03/2024
Date Signed: 09/03/2024 01:57:09 PM

Document Has Been Signed on 09/03/2024 01:57 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 FACILITY		FACILITY NUMBER:	342701444
ADMINISTRATOR:	PADUA, NICHOLAS		FACILITY TYPE:	740
ADDRESS:	3391 JOLA CIRCLE		TELEPHONE:	(916) 661-2940
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95832
CAPACITY:	6	CENSUS: 6	DATE:	09/03/2024
TYPE OF VISIT:	Office	ANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Lilibeth Meza		TIME COMPLETED:	11:00 AM

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An announced Office Meeting was conducted today, 9/3/24, at 10am, in the Sacramento Regional Office via Microsoft Teams. The purpose of this office meeting is to discuss the Decision & Order (D&O) that was set in place on 8/30/24 and to address any questions regarding the Stipulation and the Assisted Living Waiver Program (ALWP). Currently, facility has 6 residents in care.

Present in this meeting were: Regional Manager Stephenie Doub, Licensing Program Manager Stephen Richardson, Licensing Program Analyst(s) Victoria Brown and Arvin Villanueva, Section Chief HCBS, Maryjo Tobola DHCS, Unit Chief Labor Compliance Unit, Andrew Chen DHCS, Manager Operations ALWP DHCS, Mercedes Ortiz DHCS, Section Chief Provider Enrollment, Michael Luu ALWP DHCS, and Lillibeth Meza as Licensee/Representative for Home Sweet Home II Assisted Living Facility.

Issues discussed during this meeting:

The D&O was read to and discussed with Lilibeth Meza: Per Decision and Order (D&O), on 8/30/24, a decision was issued due to Lilibeth Meza’s failure to respond to certain issues. As part of the order, the license associated with the care facility will be revoked, and a Administrator certificate will either be revoked or forfeited. Meza is also barred from holding any role in a licensed facility for two years from the effective date of the decision. She has seven days to request reconsideration of the default decision, provided she can offer a valid reason for her earlier non-response. The decision will take effect on 11/30/24.
Change of Ownership (CHOW) plans and timeline submission: Applications for new ownership of Home Sweet Home 2 and Serrano facilities are in process, with the Centralized Application Bureau (CAB) notified of the default decision. Continue working on CHOW applications and liaising with CCLD for expedited processing.

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SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Arvin Villanueva	TELEPHONE: 916-208-0023
LICENSING EVALUATOR SIGNATURE:	DATE: 09/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 FACILITY	FACILITY NUMBER: 342701444
	VISIT DATE: 09/03/2024

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ALWP benefits will cease for participating residents unless they relocate to an ALWP certified facility. It was emphasized that the decision for resident(s) to not relocate to another facility is the choice of the resident(s). However, if resident(s) do not choose to relocated to a certified ALWP facility, they will lose their benefits and will need to re-enroll in the ALW program once the new owners are ALWP certified. Re-enrollment for residents in ALWP: waiting list can take up to 1 year and payment will not be retroactive. The new Licensees will need to become certified for ALWP as a Medi-Cal Provider.
Notices: 60-day notices to be provided to Community Care Licensing (CCLD) by close of business day on 9/3/24. 60-day notices to be provided to residents and/or their responsible parties by close of business day on 9/4/24. Note that an updated notification has not been provided to the residents and/or their responsible parties at this time.
Department of Health Care Services regarding ALWP: Review of DHCS website for participating ALWP facilities. The ALWP is not transferable to the new owners. Applications for CHOW cannot be fully processed until CCLD grants the new license. Billing and payments with ALWP can continue until 11/4/24; after this date, resident(s) participating in this program will need to reapply for ALWP benefits if they decide to stay at current facility.

The facility has stated they will do the following:

Submit 60-day notices to be provided to the resident(s) and/or their responsible parties regarding the D&O to CCLD by close of business day on 9/3/24.
Provide the 60-day notifications to resident(s) and /or their responsible parties regarding the D&O by the close of business day on 9/4/24.
Ensure Accusation is posted in a prominent place in all the facility.
submit relocation information of each resident for intended relocations and actual relocations.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies were cited during this visit. A copy of this report was provided via email for signature.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Arvin Villanueva	TELEPHONE: 916-208-0023
LICENSING EVALUATOR SIGNATURE:	DATE: 09/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2024

LIC809 (FAS) - (06/04)

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