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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600821
Report Date: 04/28/2022
Date Signed: 04/28/2022 10:59:16 AM


Document Has Been Signed on 04/28/2022 10:59 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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:HOME SWEET HOME SENIOR CAREFACILITY NUMBER:
415600821
ADMINISTRATOR:NEDILJKA MATIJASFACILITY TYPE:
740
ADDRESS:1560 BRYANT STREETTELEPHONE:
(650) 992-2727
CITY:DALY CITYSTATE: CAZIP CODE:
94015
CAPACITY:55CENSUS: 30DATE:
04/28/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator, Iren LudnayTIME COMPLETED:
11:15 AM
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On 4/28/2022, Licensing Program Analyst (LPA) Murial Han conducted an unannounced Case Management visit concerning an incident that was reported by the facility. LPA met with the administrator, Iren Ludnay and explained the purpose of the visit.

On 4/7/2022, the facility report an incident that happened on 3/29/2022 concerning resident #1 (R1) vomited in dining room after lunch. Staff #1 (S1) reported it to administrator who asked Staff #2(S2) to evaluate R1. S2 observed some mucus came out of R1's mouth and R1 was not responsive. S2 instructed administrator to call 911 while S2 was performing Heimlich Maneuver and eventually Cardiopulmonary Resuscitation (CPR). The paramedics arrived and continued with CPR then transferred R1 to the hospital where she passed away.

During today's visit, LPA Han interviewed the administrator, tour the dining room and collected documents.

This incident requires further investigation.

This report is discussed and reviewed with administrator.

A copy is provided.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2022
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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