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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700043
Report Date: 11/08/2021
Date Signed: 11/08/2021 10:09:14 AM

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: 5DATE:
11/08/2021
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Tavaita SeruvatuTIME COMPLETED:
10:15 AM
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Licensing Program Analyst (LPA) Tung Truong arrived unannounced to conduct a Case Management visit on 11/8/21 at 8:45 AM. LPA met with Tavaita Seruvatu, Caregiver, and stated the purpose of today’s 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.

The purpose of today’s visit is to ensure the instructions provided in the Health and Safety Code Section 1569.38 are being followed according to the accusation. The instructions include, but not limited to, the requirement to notify the residents and Local Ombudsman (LTCO) within 10 days and to post a notice in a conspicuous location advising that an action is pending. The accusation was served on 10/6/21.

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. LPA has received a copy of the notifications and observed the posting of the accusation, and the (LTCO) was called and letter was sent.

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: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2021
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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