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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397002694
Report Date: 05/26/2023
Date Signed: 07/27/2023 10:47:30 AM


Document Has Been Signed on 07/27/2023 10:47 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: 4DATE:
05/26/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:S.SuzaraTIME COMPLETED:
02:45 PM
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The following deficiencies, initially cited during a visit on 05/18/2023, have been cleared:

Section Cited: 87411(a)Date Due: 05/19/2023
Plan of Correction:
The facility shall conduct an in-service training with staff to go over what and how staff shall ensure that residents do not AWOL. Administrator shall send the in-service training materials, plan on how staff will ensure residents do not AWOL		Corrections:
Cleared By Visit		Clearance Date:
05/26/2023
Section Cited: 87468.1Date Due: 05/26/2023
Plan of Correction:
The facility administrator will ensure that all staff receive in-service training regarding the personal rights of the clients and proof of this training will be submitted to CCL by the POC due date.		Corrections:
Cleared By Visit		Clearance Date:
05/26/2023
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 05/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2023
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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