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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005496
Report Date: 01/20/2022
Date Signed: 01/31/2022 08:02:28 AM

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 HOMEFACILITY NUMBER:
397005496
ADMINISTRATOR:IRENE SAUSEDAFACILITY TYPE:
740
ADDRESS:1330 W. WALNUT STREETTELEPHONE:
(209) 369-7272
CITY:LODISTATE: CAZIP CODE:
95242
CAPACITY:10CENSUS: 10DATE:
01/20/2022
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Irene Sauseda, AdministratorTIME COMPLETED:
11:25 AM
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At 9:00am, Licensing Program Analyst (LPA) T. White arrived to conduct an unannounced annual/required inspection on 01/20/2022. LPA met with Administrator, Irene Sauseda and explained the purpose of today’s inspection. LPA was allowed entry into the facility that is licensed to serve a total capacity of 11 residents of which 4 may be ambulatory, 6 non-ambulatory, and 1 bedridden.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 72 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 118.2 degrees Fahrenheit. There is a minimum of 7-day supply of nonperishable and 2-day of perishable foods.

LPA observed smoke detector is interconnected with the fire department. Carbon monoxide was in operating condition during inspection. Fire extinguisher was last serviced on November 14, 2021. First aid kit was observed to be complete. Fire drill was last conducted on 12/30/2021. LPA observed completed mitigation plan. LPA reviewed 3 resident files and 3 staff files.

No deficiencies cited during today's inspection. Exit interview conducted with Administrator and a copy of report given.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana WhiteTELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:

DATE: 01/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2022
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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