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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700200
Report Date: 12/21/2020
Date Signed: 12/23/2020 11:50:10 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 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:
12/21/2020
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Javier Castro Jr.TIME COMPLETED:
05:00 PM
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A Non-Compliance Conference was conducted today in the Sacramento South Regional Office. The purpose of this Non-Compliance Conference meeting is to discuss the high volume of complaints/inability to remain in substantial compliance with the regulations/or specific incident that has occurred in the last 24 months. Present in the meeting is Regional Manager Krystall Moore, Central Application Bureau (CAB) Staff Services Manager II Hao Nguyen, CAB Staff Services Manager I Tracy Thompson, Licensing Program Manager (LPM) Czarrina Camilon-Lee, LPM Liza King, LPM Stephen Richardson, Acting Regional Manager Laura Munoz, LPM Stephenie Doub, Licensing Program Analyst (LPA) Victoria Brown, LPA Tung Truong, LPA Jasmine McCrory, and Licensees and Administrator(s) Mike Her and Bianca Castro, LOVE AND SERENITY LLC, representative Javier Castro Jr. The Non-Compliance Conference process was explained during this meeting.


Issues discussed during the meeting were:
· The amount of complaint's filed against this facility within the last 12 months
· Residents sleeping in other areas of the home such as chair and sofa-no exception request was submitted
· Insufficient staffing/Supervision issues
· Incomplete records
· Unlicensed Complaint
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: 916-201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2020
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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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 VINTAGE PARK
FACILITY NUMBER: 342700200
VISIT DATE: 12/21/2020
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· Change in organizational structure
· Fire Clearance
· Pending/Denied Applications
· AWOLs/Injuries/False Claims
· Physical Plant with accessible chemicals due to inadequate locking device, not clean with debris on floors and bowel/bladder odor in rooms
· Medications not destroyed as required and accessible
· Basic services such as grooming/incontinence needs not met
· 911 was not used for 5 days
· Licensee/Administrator accountability- Any changes over 50% for any facility, CCL will be consulted prior to the change including the change of administrators

The facility has stated they will do the following to achieve continued and substantial compliance:
· New/On-Call staff will have appropriate supervision
· There will be a full time Executive Director/Administrator at the facility for 40 hrs per week
· Submit LIC500 Personnel Summary for each facility to include the Administrator presence for 40 hrs
· Submit LIC308 Designation of person(s) in charge in the absence of the Administrator for each facility
· Submit incontinence and body check forms created to observe changes in the residents and keep completed copies in the resident file.
· Conduct re-appraisals for all residents for each facility by 1/15/2021 hiring more staff if necessary
· Continue the use of the door alarms and provide supervision for those with wandering behaviors.
· Submit proof of staff training in the areas of observation, incontinence, personal rights and AWOL.
· Continue weekly activity schedule
· Increased monitoring
· Administrator will review MARs daily to ensure medications were given as prescribed.
· Create policies and procedures to ensure facility is clean and disinfected on every shift as stated in the Provider Information Notice (PIN 20-02-HCS)
· Submit all required documents to change administrator
· Agrees to not change corporate structure without proper notifications to the Department.

Completing the Non-Compliance Conference does not deprive the Department of its authority to take appropriate formal legal action under the Health and Safety Code if such action is deemed necessary by the Regional Manager.
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 Mike Her at the request of Javier Castro Jr. 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: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: 916-201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2020
LIC809 (FAS) - (06/04)
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