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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700043
Report Date: 08/30/2021
Date Signed: 08/30/2021 01:57:30 PM

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:
08/30/2021
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Tavaita Servatu, CaregiverTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Case Management visit on 8/30/21 at 1:00PM. LPA met with Tavaita Seruvatu, Caregiver, and stated the purpose of todays visit. LPA spoke with Mike Her, Administrator stating LPA presence at the facility. LPA toured and inspected the physical plant to ensure there are no safety hazards to residents.

This visit is to advise the Licensee/Administrator to ensure the Health and Safety Code Section 1569.38 Posting of licensing reports; disclosure to new residents are being followed according to the accusation. A notice regarding the accusation shall be posted in a conspicuous location advising that an action is pending. LPA observed 6 residents and 2 caregivers during this visit.
The temperature inside the facility was observed to be at 75*F which is within the required range of 68-85*F. The hot water temperature was not measured during this visit. 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 the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited. An exit interview was conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2021
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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