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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700043
Report Date: 09/21/2021
Date Signed: 09/21/2021 12:03:21 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:
09/21/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator, Mike HerTIME COMPLETED:
12:30 PM
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On 9/21/2021 at 11:05 AM, Licensing Program Analyst (LPA) Tung Truong arrived unannounced to conduct a POC visit. LPA met with Administrator Mike Her and explained the purpose of today’s visit.

LPA toured the facility and reviewed document submitted for plans of correction. LPA observed that the deficiencies cited on 09/17/2021 have been cleared.

*Deficiency cited under Title 22 Regulation 87411(a) and 87303(a) has been cleared. Licensee complied with the terms of the POC by POC due date.

Facility was provided POC cleared letter.

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021
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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