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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005496
Report Date: 01/31/2024
Date Signed: 01/31/2024 03:46:58 PM


Document Has Been Signed on 01/31/2024 03:46 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 HOMEFACILITY NUMBER:
397005496
ADMINISTRATOR:IRENE SAUSEDAFACILITY TYPE:
740
ADDRESS:1330 W. WALNUT STREETTELEPHONE:
(209) 369-7272
CITY:LODISTATE: CAZIP CODE:
95242
CAPACITY:10CENSUS: 7DATE:
01/31/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Rosette PerezTIME COMPLETED:
03:45 PM
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Licensing Program Analysts (LPA) Kesha Lewis arrived at the facility unannounced for the purpose of conducting a case management incident inspection regarding incident report received dated 01/02/2024 . LPA explained purpose of visit to staff.

The incident report was regarding a resident falling and being sent to the hospital with a head injury. The facility fall policy and fall plan for R1 will be emailed to LPA by 2/5/2024. The facility provided a copy of R1'S IPP, discharge paperwork and 602 (Physician's report).

This matter is still under investigation.

An exit interview was conducted and a copy of this report was given.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Kesha LewisTELEPHONE: (916) 764-1024
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2024
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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