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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700043
Report Date: 05/04/2022
Date Signed: 05/04/2022 04:38:23 PM


Document Has Been Signed on 05/04/2022 04:38 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:LOVE AND SERENITY OF ELK GROVEFACILITY NUMBER:
342700043
ADMINISTRATOR:HER, MIKEFACILITY TYPE:
740
ADDRESS:10339 SAGRES WAYTELEPHONE:
(916) 667-8465
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY:6CENSUS: 6DATE:
05/04/2022
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Josateki LeleivuneTIME COMPLETED:
04:45 PM
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On 5/4/22 at 3:10 PM, Licensing Program Analyst (LPA) Tung Truong arrived unannounced to conduct a quarterly Case Management inspection due to a current stipulation order. LPA was met by Josateki Leleivune, Caregiver and stated the purpose of the visit. LPA spoke with Administrator Mike Her on the phone and explained the purpose of today’s visit. Administrator stated he was unable to come to the facility and advised that staff Josateki can assist with today’s visit.

The purpose of today’s visit is to ensure the Stipulation Order is being followed. LPA observed posting of the stipulation. LPA observed facility has auditory device on exit door. LPA toured and inspected the physical plant to ensure there are no safety hazards to residents. LPA observed 6 residents and 2 caregivers during this visit, who are fingerprint cleared. The hot water temperature was measured at 106*F during this visit which is within the required range of 105-120*F. LPA observed fire extinguisher(s), smoke and carbon monoxide detectors, and central heating and air in the facility. LPA observed 2-day perishables and 7-day non-perishables. LPA observed centrally stored medications area to be locked and inaccessible to residents. The first aid kit observed and is complete.

Licensee was previously informed that CCL shall receive copies of the notifications to all residents and/or responsible parties and that civil penalties could be assessed if licensee fails to follow the requirements. Administrator Mike Her stated the copies of the notifications to all residents were sent to Licensing.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited. An exit interview was held, and a copy of the report was left at the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2022
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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