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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397002694
Report Date: 12/04/2023
Date Signed: 12/05/2023 01:42:17 PM


Document Has Been Signed on 12/05/2023 01:42 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 FOR THE ELDERLYFACILITY NUMBER:
397002694
ADMINISTRATOR:SUZARA, SARAHFACILITY TYPE:
740
ADDRESS:14110 JASPER STREETTELEPHONE:
(209) 470-7772
CITY:LATHROPSTATE: CAZIP CODE:
95330
CAPACITY:6CENSUS: 5DATE:
12/04/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Sarah SuzaraTIME COMPLETED:
03:30 PM
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Unannounced Plan of Correction visit conducted out at this facility by Licensing Program Analyst (LPA) Charlie Yang. This LPA was met by the facility designated Administrator, Sarah Suzara, at this time. A brief interview was conducted with the facility designated Administrator.
Current census was 5 residents.
The purpose of this visit was to follow up on the deficiencies and Plan of Correction that was set from a prior annual visit conducted on 11/08/2023. The following Plan of Correction was expected to be completed and submitted into CCL by the due date:

In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

A review of the Plan of Correction was conducted. Letters for clearances were printed and a copy was left with the facility designated Administrator at this time.

No further deficiencies were observed or cited at this time.

Exit Interview
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:
DATE: 12/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/04/2023
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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