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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397002694
Report Date: 10/17/2022
Date Signed: 10/18/2022 09:05:31 AM

Document Has Been Signed on 10/18/2022 09:05 AM - It Cannot Be Edited

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: 6DATE:
10/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Sarah SuzaraTIME COMPLETED:
03:30 PM
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On 10/17/2022 at 1:15pm, Licensing Program Analyst (LPA) Arielle Pascua arrived at this facility unannounced to conduct an annual infection control visit. LPA Pascua was greeted by staff member, Shirley Callorina and was asked to call the Administrator, Sarah Suzara to let her know that licensing was present at this time. Upon arrival the LPA observed a centralized screening point equipped with hand sanitizer and masks. Shortly after, LPA Pascua met with Administrator Suzara explained the purpose of the visit. The purpose of the visit is to conduct an annual infection control visit. This facility is licensed for 6 residents, two of which may be non-ambulatory. The administrator has an active certificate #6005038740 and expires on 11/15/2023. Current census was 6.
At 1:25pm, LPA Pascua initiated a tour with Administrator Suzara.
At 1:25pm, LPA Pascua toured the laundry room and garage. Washer and Dryer were observed to be in good repair. A linen closet was identified in the garage and was observed to be a sufficient amount of linens for 6 residents at this time. LPA observed toxins, laundry detergent and other supplies to be in locked cabinets located in the garage and made inaccessible to the residents in care.
At 1:30pm, LPA Pascua toured the kitchen. LPA observed there to be a sufficient amount of 2-day perishable and 7-day non-perishable food supply. Kitchen cabinets, appliances, and sink were observed to be in good repair. LPA observed knives to be located in a closet located in the hallway next to the kitchen. A fire extinguisher located in the kitchen was observed to be purchased on 03/07/2022.
At 1:35pm, LPA Pascua toured the dining room and living room. Windows, blinds, and screens were in good repair. Furniture and furnishings intended for resident use were observed to be in maintained and in good repair.
At 1:40pm-1:55pm, LPA Pascua toured 4 shared resident bedrooms. Resident furniture was observed to be sufficient to meet their needs at this time.
At 2:00pm, LPA toured two resident bathrooms. Hot water temperature was measured to be 112 degrees. Grab bars were observed to be stable and in good repair at this time.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 ELDERLY
FACILITY NUMBER: 397002694
VISIT DATE: 10/17/2022
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At 2:05pm, LPA Pascua toured the exterior of the physical plant. Perimeter fence was observed to be stable and gates were in good repair.
At 2:10-2:25pm, LPA Pascua observed a locked centralized stored medication cabinet located in the kitchen. Along with the Administrator Suzara, the LPA observed, reviewed, and compared resident medication and medication dispensing logs. First Aid Kit was present and contained all of the required components.
The following forms and documents were requested to be updated and submitted into CCL

-LIC 308

-LIC 400

-LIC 500

-LIC 610

As a result of this visit, no deficiencies were observed or cited during this annual visit. An exit interview was conducted and copy of the 809 and 809-C was provided to Administrator Suzara.

SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2022
LIC809 (FAS) - (06/04)
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