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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700200
Report Date: 10/31/2024
Date Signed: 10/31/2024 03:37:21 PM

Document Has Been Signed on 10/31/2024 03:37 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:LOVE AND SERENITY OF VINTAGE PARKFACILITY NUMBER:
342700200
ADMINISTRATOR/
DIRECTOR:		BIANCA G CASTROFACILITY TYPE:
740
ADDRESS:8901 SONOMA VALLEY WAYTELEPHONE:
(916) 509-9693
CITY:SACRAMENTOSTATE: CAZIP CODE:
95829
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
10/31/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Staff on duty (S1)TIME VISIT/
INSPECTION COMPLETED:
03:38 PM
NARRATIVE
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On 10/31/24, Licensing Program Analyst (LPA) Arvin Villanueva conducted an unannounced required 1 year annual inspection visit. LPA met with staff on duty (S1) and explained purpose of visit. Administrator Bianca Castro was notified of the visit and gave permission to S1 to sign this report. Present during today's visit were 5 residents in care with 2 staff on duty (S1 and S2).

LPA and S1 evaluated the physical plant to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms, resident bathrooms, living and dining room and outdoor areas. LPA observed the facility to be free of odor, clean and in good repair at this time. LPA observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility. LPA measured the hot water temperature measured at 105 degrees F in the master bathroom. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Fire extinguisher observed in the kitchen was last inspected on 4/5/24. Smoke and carbon monoxide detectors were observed, tested and operable at this time. First aid kit was checked and Technical Advisory (TA) was provided to obtain missing items. LPA observed centrally stored medications, toxins, and sharp objects were kept locked and inaccessible to residents in care. Swimming pool was observed to be fenced, locked and inaccessible to residents in care. Facility conducts quarterly drills and last drill was conducted on 8/20/24.

LPA reviewed 3 staff files (S1, S2, and Administrator) .LPA observed all staff and resident files complete. All 3 staff reviewed have criminal record clearance and are associated to the facility. All 3 staff have current First Aid/CPR certificates. Administrator certificate expires May 3, 2026. Review of S1's file revealed that S1 just started on 10/8/24 but S1's health screen was completed 1/13/23 which was done more than 6 months prior to working at this facility.

{1 of 2}
Stephen RichardsonTELEPHONE: (916) 263-4700
Arvin VillanuevaTELEPHONE: 916-208-0023
DATE: 10/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/31/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 12
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: LOVE AND SERENITY OF VINTAGE PARK
FACILITY NUMBER: 342700200
VISIT DATE: 10/31/2024
NARRATIVE
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LPA reviewed 5 resident files (R1 - R5). Through record review, it was revealed that facility staff have been managing resident cash funds by the evidence of ledger for accounting resident cash and resident wallet in resident's binder which is being kept locked by facility staff. Per interview with staff, resident needs help managing their cash money due to forgetfulness and diagnosis. Per interview with Adminsitrator, the facility does not have a current surety bond established. Review of facility's Affidavit Regarding Resident Cash Resources (FORM LIC 400) indicated that facility has opted not to handle any cash resources of persons within the facility.

LPA reviewed 2 residents' medications for accuracy. Through review of R5's medication, it was revealed that Medication_1(M1) 400mg to be taken as needed has an discard by date of 5/19/24. Review of R5's medication record revealed that R5 has a prescription for this medication. Interview with staff and review of medication administration record (MAR) revealed that R5 has not taken this medication the past 3 months. Further review of R5's medication revealed that R5 has Medication_2 (M2) that does not have pharmacy label and no box to be found. According to staff interview, R5 has used this medication as PRN in the past 7 days. LPA is unable to located this medication in Centrally Stored Medication Record nor in the Prescription Order at this time.

LPA requested the following documents: LIC 308 Designation of Facility Responsibility, LIC 500 Personnel Report, and copy of current Liability Insurance.

Per California Code of Regulations, Title 22 deficiencies are being cited during today's inspection. Failure to correct deficiencies may result in civil penalties.

Deficiencies and plan of corrections were discussed with the Administrator over the phone.

An exit interview was conducted with S1. A copy of this report and appeal rights were provided.

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SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Arvin VillanuevaTELEPHONE: 916-208-0023
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2024
LIC809 (FAS) - (06/04)
Page: 2 of 12
Document Has Been Signed on 10/31/2024 03:37 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: LOVE AND SERENITY OF VINTAGE PARK
FACILITY NUMBER: 342700200

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(e)
Incidental Medical and Dental Care Services
(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above. Medication_2 (M2) did not have a pharmacy label, and no prescription order available for review during this visit. Interview with staff, resident as been using this medication as PRN. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/01/2024
Plan of Correction
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Per discussion, the Administrator has agreed to submit a written statement of understanding of the regulation cited above and send written statement to the Department by POC due date.
Administrator will obtain current order of all R5's medication from their doctor and submit proof to the Department once obtained but no later than 11/8/24.
Administrator will obtain pharmacy label from the pharmacy for medication M2 and submit photo of label to the Department once obtained but no later than 11/8/24.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Arvin VillanuevaTELEPHONE: 916-208-0023
LICENSING EVALUATOR SIGNATURE:
DATE: 10/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2024
LIC809 (FAS) - (06/04)
Page: 3 of 12
Document Has Been Signed on 10/31/2024 03:37 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: LOVE AND SERENITY OF VINTAGE PARK
FACILITY NUMBER: 342700200

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87216(a)
(a) Each licensee, other than a county, who is entrusted to safeguard resident cash resources, shall file or have on file with the licensing agency a copy of a bond issued by a surety company to the State of California as principal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above. During resident record review, it was revealed that facility staff has been managing resident’s cash money. Record review and interview revealed that facility has opted not to handle resident cash resources and therefore did not have surety bond in place. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/08/2024
Plan of Correction
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Per discussion with administrator, she plans to discuss with resident’s responsible party that they will not be handling resident’s money moving forward.
Administrator agreed to submit a statement of understanding of the regulation cited and submit statement to the Department by POC due date.
Type B
Section Cited
CCR
87411(f)
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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by based on records reviewed, one employee did not have proof of current TB test or health screen on file. Licensee did not retain proof that a health screening, including a test for tuberculosis was performed by or under the supervision of a physician not more than 6 months prior to or seven days after employment. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/08/2024
Plan of Correction
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Per discussion with administrator, they will have the employee obtain a current health screening/TB Test. The licensee shall submit a copy of the health screening/ TB test to LPA via email by 11/8/24.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Arvin VillanuevaTELEPHONE: 916-208-0023
LICENSING EVALUATOR SIGNATURE:
DATE: 10/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2024
LIC809 (FAS) - (06/04)
Page: 11 of 12
Document Has Been Signed on 10/31/2024 03:37 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: LOVE AND SERENITY OF VINTAGE PARK
FACILITY NUMBER: 342700200

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(i)
Incidental Medical and Dental Care Services. When prescription medications must be destroyed, specific procedures must be followed and itemized records must be kept for a minimum of three years.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, interviews and record reviews, LPA found expired PRN medication (M1) for resident R5 during a medication review. According to review of medication label, M1 was supposed to be discarded 5/19/24. According to staff interview and record review of MAR, R5 has not used this medication for a while. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/08/2024
Plan of Correction
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Per discussion, Administrator shall conduct a medication audit on medications. Administrator to ensure that all staff responsible for administration of medication are re-trained on facility protocol/procedure as it relates to destruction of expired/discontinued medications a timely manner.
Administrator shall email LPA with training date for staff by the POC due date and then shall submit training logs with roster of attendees to LPA after the training as well as a plan on how medications will be logged and who and how many times medications will be checked for expiration dates. Administrator shall send all documentation by 11/8/24.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Arvin VillanuevaTELEPHONE: 916-208-0023
LICENSING EVALUATOR SIGNATURE:
DATE: 10/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2024
LIC809 (FAS) - (06/04)
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