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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005496
Report Date: 04/29/2024
Date Signed: 04/29/2024 03:01:34 PM

Document Has Been Signed on 04/29/2024 03:01 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/
DIRECTOR:		IRENE SAUSEDAFACILITY TYPE:
740
ADDRESS:1330 W. WALNUT STREETTELEPHONE:
(209) 369-7272
CITY:LODISTATE: CAZIP CODE:
95242
CAPACITY: 10CENSUS: 7DATE:
04/29/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Rosette PerezTIME VISIT/
INSPECTION COMPLETED:
03:00 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).

LPA conducted facility tour with staff. LPA observed facility common areas, various resident rooms, kitchen area and hallways. Facility was observed by LPA to be clean and sanitary. Floors and walls were clean without prominent stains. Facility was observed to contain no foul odors. Food supply was adequate with 7 days of non-perishables and 2 days of perishable items in place. Fire extinguisher was full charged and current. Room temperature was 71*F. Smoke alarms and carbon detectors are functioning properly. Current census is 7. No obstructions to fire exits noted during today's tour.

An exit interview was conducted and a copy of this report was given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE: DATE: 04/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/29/2024
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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