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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700043
Report Date: 02/24/2022
Date Signed: 02/24/2022 09:55:32 AM


Document Has Been Signed on 02/24/2022 09:55 AM - 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:
02/24/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Mike HerTIME COMPLETED:
10:10 AM
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Licensing Program Analyst (LPA) Tung Truong arrived unannounced to conduct a Case Management visit on 2/24/22 at 9:10 AM. Prior to entering the facility, LPA Truong called the facility and spoke to staff, who confirmed no residents or staff have had any symptoms of COVID-19 in the last 10 days. Upon LPAs arrival, Caregiver Tavaita Servatu was present at facility and contacted Administrator Mike Her who arrived a bit later. LPA met with Administrator Mike Her and explained the purpose of the visit. 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 70 degrees Fahrenheit which is within the required range of 68-85 degrees Fahrenheit . The hot water temperature was observed to be 107.6 degrees Fahrenheit. LPA observed 2-day perishables and 7-day non-perishables. 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.

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: 02/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2022
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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