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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700200
Report Date: 12/06/2024
Date Signed: 12/06/2024 12:04:29 PM

Document Has Been Signed on 12/06/2024 12:04 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:
12/06/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Bianca CastroTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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On 12/06/24, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced case management visit to this facility. The LPA identified herself upon arrival, stated the purpose of the visit and asked to meet with the Designated Facility Administrator, Bianca Castro. The administrator was notified by staff and arrived shortly after.

LPA began the visit by comparing the LIC 500 with the Guardian roster to ensure all employees had completed and passed the background clearance process. The 4 employees listed on the LIC 500 all had the required clearances at the time of this case management inspection.

LPA conducted a walkthrough of the facility. Present at the time of this visit were 5 residents with 2 staff on duty. LPA introduced herself to each resident and spoke briefly with each. LPA measured the hot water to ensure it was between 105 and 120 degrees Fahrenheit and in compliance at the time of this inspection.

LPA interviewed Bianca Castro who stated there had recently been a Covid outbreak at the facility and went on to state that she had notified the Sacramento Pubic Health Department (SPHD) and sent the required incident reports to Community Care Licensing (CCL). LPA requested a copy of the facility's infection control plan, a list of what steps were taken to control the spread of COVID, documentation showing when SPHD was notified, and copies of the incident reports sent to CCL by the close of business today, 12/06/24.

She further disclosed information regarding an incident that occurred on 11/03/24. The Designated Facility Administrator had not sent a report to CCL yet as they stated they thought they had 7 days to do so. LPA provided technical assistance with regard to the California Code of Regulations, Title 22 Reporting requirements:
87211 Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:
Stephen RichardsonTELEPHONE: (916) 263-4746
Kimberly ViarellaTELEPHONE: (916) 809-5764
DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2024
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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: LOVE AND SERENITY OF VINTAGE PARK
FACILITY NUMBER: 342700200
VISIT DATE: 12/06/2024
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(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.
(A) Death of any resident from any cause regardless of where the death occurred, including but not limited to a day program, a hospital, en route to or from a hospital, or visiting away from the facility.
(B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision.
(C) The use of an Automated External Defibrillator.
(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.
(2) Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate.
(3) Fires or explosions which occur in or on the premises shall be reported immediately to the local fire authority; in areas not having organized fire services, within 24 hours to the State Fire Marshal; and no later than the next working day to the licensing agency.
(b) Any suspected physical abuse that results in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within two (2) hours as required by Welfare and Institutions Code Section 15630(b)(1). "

LPA requested the following documentation be sent to CCL by the close of business today, 12/06/24:
* For Resident 1 (R1): ID/Emergency Contact Information, LIC 602, application, pre-appraisal, care/observation notes for 11/2024 and 12/2024.
LPA also requested:
*Names and contact information for all staff working at the facility for the months of November and December.

Due to time constraints and the need for reviewing infection control information, this LPA will return at a later date to complete this case management

No deficiencies were cited during today's visit. A copy of this report was provided and an exit interview conducted with Bianca Castro.

SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024
LIC809 (FAS) - (06/04)
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