342700043-1-21-2022-27-AS-TTRG-CAVVGB-20220121152515

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700043
Report Date: 01/21/2022
Date Signed: 01/21/2022 03:25:21 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 GROVE		FACILITY NUMBER:	342700043
ADMINISTRATOR:	HER, MIKE		FACILITY TYPE:	740
ADDRESS:	10339 SAGRES WAY		TELEPHONE:	(916) 667-8465
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95757
CAPACITY:	6	CENSUS: 6	DATE:	01/21/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:40 PM
MET WITH:	Mike Her, Administrator		TIME COMPLETED:	03:40 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 01/21/2022 at 1:40 pm, Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced to conduct an annual inspection visit. Prior to entering the facility, LPA Truong called to confirm if any residents or staff have had any symptoms of COVID-19 in the last 10 days. LPA met with Administrator Mike Her and explained the purpose of today’s visit. Administrator holds current certification #6038882740 and expires on 4/11/2022. The facility is licensed to serve up to six (6) non-ambulatory residents of which 1 may be bedridden. Approved hospice waiver for one (1). There are currently 6 residents who reside at this facility. LPA toured the facility with Administrator Mike Her on 01/21/2022 at 1:55 pm. LPA inspected the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms, resident bathrooms, laundry room, and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA observed the facility is clean and in good repair. LPA observed sufficient furniture and lighting throughout the facility. LPA observed bedrooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition and properly maintained. The hot water temperature was observed to be 116.4 degrees Fahrenheit. Food supply is adequate for 2-day perishable and 7-day nonperishable. LPA observed knives and toxins to be locked away and inaccessible to clients. Smoke and carbon detectors were in good repair. Fire extinguisher and first aid kit was up to date. LPA checked medication storage and found medication to be locked away and inaccessible to clients. LPA also conducted the infection control domain tool. Report continued on 809-C

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 01/21/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 GROVE	FACILITY NUMBER: 342700043
	VISIT DATE: 01/21/2022

NARRATIVE

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The facility mitigation plan was submitted to CCLD, and it was approved on 6/17/2021. Facility has routine symptom screening checks for clients, staff, and visitors. The facility has a symptom check binder for staff, clients, and care staff. Hand Hygiene procedures have been implemented. Facility had Covid-19 posters throughout the facility, and the facility has implemented Covid-19 mitigation plan.

Administrator was informed to send updated copies of the following documents to CCL within 15 days:
(1) LIC308 Designation of Administrative Responsibility
(2) LIC500 Personnel Report
(3) LIC610 Emergency Disaster Plan
(4) Proof of Current Liability Insurance
(5) Control of Property

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was conducted and a copy of this report was provided.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 01/21/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2022

LIC809 (FAS) - (06/04)

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