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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397002694
Report Date: 11/09/2021
Date Signed: 11/09/2021 04:13:01 PM

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 FOR THE ELDERLYFACILITY NUMBER:
397002694
ADMINISTRATOR:SUZARA, SARAHFACILITY TYPE:
740
ADDRESS:14110 JASPER STREETTELEPHONE:
(209) 470-7772
CITY:LATHROPSTATE: CAZIP CODE:
95330
CAPACITY:6CENSUS: 4DATE:
11/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Sarah Suzara, AdministratorTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Arlene Garcia conducted an unannounced annual / Infection Control visit on this date. LPA met with Sarah Suzara, Administrator.

LPA and AD, inspected physical plant including but not limited to the main kitchen, residents bedrooms and bathrooms, and dining/ living room areas.
LPA observed front yard and back yard free and clear of debris.

LPA observed sufficient 7 days non-perishable and 2 days perishable food supplies.. Hot water temperature measured 114.6 degrees in residents bathroom.
Last Fire Drill conduced dated 6/16/21. Fire extinguisher maintained 2/22//2021.
Fire alarm and carbon monoxide functional. LPA observed sharps and toxins locked.
LPA and AD observed centrally stored medications.
LPA reviewed 3 staff and 4 resident files. Resident emergency contact complete. LPA observed all staff files complete.
Administrator Certificate valid until 11/15/2021.
All persons in facility fully vaccinated. LPA observed 30 days PPE supply.

Per California Code of Regulations, Title 22 Division 6, Chapter 8, no deficiencies are being cited today in violation of California Code of Regulations. Exit interview held with AD and a copy of report given .
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D GarciaTELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2021
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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