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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700200
Report Date: 11/10/2022
Date Signed: 11/10/2022 09:26:52 AM


Document Has Been Signed on 11/10/2022 09:26 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 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: 5DATE:
11/10/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Walesi VakararawaTIME COMPLETED:
09:35 AM
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On 11/10/22 at 8:55AM Licensing Program Analyst (LPA) Chris Hopkins arrived unannounced to conduct a quarterly Case Management inspection due to a current stipulation order. LPA was met by staff Walesi Vakararawa, and stated the purpose of the inspection.

Todays visit which is to ensure the instructions provided in the Health and Safety Code Section 1569.38 are being followed according to the stipulation. LPA toured and inspected the physical plant to ensure there are no safety hazards to residents. LPA observed 5 residents and 2 caregivers during this visit. 2 caregivers are fingerprint cleared and associated. LPA observed posting of the stipulation. The hot water temperature was measured at 110*F during this visit which is within the required range of 105-120*F. LPA observed fire extinguisher(s), smoke and carbon monoxide detectors, and central heating and air in the facility. LPA observed sufficient 2-day perishable and 7-day non-perishable food supply. LPA observed centrally stored medications area to be locked and inaccessible to residents. The first aid kit observed and is complete.

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: Christopher Hopkins-ClarkeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/10/2022
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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