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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700200
Report Date: 09/10/2023
Date Signed: 09/10/2023 12:59:17 PM


Document Has Been Signed on 09/10/2023 12:59 PM - 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:
09/10/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Bianca Castro - AdministratorTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced quarterly Case Management inspection due to a current stipulation order. LPA was met by administrator and stated the purpose of the inspection.

Today's visit which is to ensure the instructions provided in the Health and Safety Code Section 1569.38 are being followed according to the stipulation. The instructions include, but not limited to, the requirement to notify the residents and Local Ombudsman (LTCO) within 10 days and to post a notice in a conspicuous location advising that an action is pending.

LPA toured and inspected the physical plant to ensure there are no safety hazards to residents. LPA observed five residents and two caregivers during this visit. All caregivers are fingerprint cleared and associated. LPA observed posting of the stipulation. The hot water temperature was measured at 114.8*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 (CCR's) - Title 22, Division 6, Chapter 8, no deficiencies are being cited.

An exit interview was conducted with administrator and a copy of this report was provided.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 09/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2023
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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