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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700200
Report Date: 11/19/2020
Date Signed: 11/19/2020 03:28:35 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 VINTAGE PARKFACILITY NUMBER:
342700200
ADMINISTRATOR:BIANCA G CASTROFACILITY TYPE:
740
ADDRESS:8901 SONOMA VALLEY WAYTELEPHONE:
(916) 509-9693
CITY:SACRAMENTOSTATE: CAZIP CODE:
95829
CAPACITY:6CENSUS: 6DATE:
11/19/2020
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Bianca CastroTIME COMPLETED:
01:30 PM
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An Informal Conference was conducted today in the Sacramento Regional Office via Webex. The purpose of this informal conference meeting is to discuss the high volume of deficiencies/complaints/inability to remain in substantial compliance with the regulations/or specific incidents that has occurred within the last 2 years. Present in the meeting is Licensing Program Manager(s) Stephenie Doub and Czarrina Camilon-Lee, Licensing Program Analyst (s) Victoria Brown and Tung Truong, and Bianca Castro representative of Love And Serenity Of Vintage Park. The informal conference process was explained during this meeting.

The facility was licensed on 10/16/2017, for a capacity of 6 Non-Ambulatory residents of which 1 may receive hospice care services. Since licensure the facility has been cited 15 violations which includes a substantiated complaint..

Bianca indicated today, that in regards to the deficiencies previously cited, all staff has received training either as a new staff or in-service for the previous staff and the training has been documented. Bianca Castro was asked to submit a current copy of the Personnel Report (LIC500) to include the Administrator to LPA Troung.

Technical Support Program (TSP) was offered as an option to assist facility with compliance. Bianca Castro opted to use the TSP and a referral will be submitted on her behalf.
Bianca Castro was reminded that Licensing Program Analysts as well as the Officer of the Day are available should she have any questions or concerns.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited during this visit. An exit interview was conducted with Bianca Castro via telephone and a copy of this report was provided via email and an electronic email read receipt confirms receiving these documents.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2020
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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