342700200-1-14-2025-27-AS-AVIA-DCWTAE-20250114133326

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700200
Report Date: 01/14/2025
Date Signed: 01/14/2025 01:33:37 PM

Document Has Been Signed on 01/14/2025 01:33 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 PARK		FACILITY NUMBER:	342700200
ADMINISTRATOR/ DIRECTOR:	TEVITA KALOULASULASU		FACILITY TYPE:	740
ADDRESS:	8901 SONOMA VALLEY WAY		TELEPHONE:	(916) 509-9693
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95829
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	01/14/2025
TYPE OF VISIT:	Case Management - Health Checks	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:15 AM
MET WITH:	Staff on duty (S1)		TIME VISIT/ INSPECTION COMPLETED:	01:45 PM

NARRATIVE

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On 1/14/2025, Licensing Program Analyst (LPA) Arvin Villanueva arrived unannounced to this facility to conduct a case management visit. LPA met with staff on duty (S1). The Administrator, Tevita Kaloulasulasu, was notified of this visit and gave permission to S1 to sign this report. Present during this visit were 5 residents in care with 1 staff on duty (S1).

During a Non-Compliance Conference (NCC) meeting with Bianca Castro, Administrator, on 11/6/2024, regarding another facility under her administration, the Department determined that increased monitoring was required to ensure the facility's compliance. The Department has also determined that licensee is not to admit new residents and to appoint new administrator. Licensee has agreed to these terms.

According to a telephone interview with the Administrator, the two staff members scheduled to work today (S2 and S3) called in sick this morning. The Administrator informed this LPA that S1 was sent to this facility to cover, but there is no second staff available to cover the shift. A review of the Guardian system shows that S1 has background clearance and is associated with this facility.

LPA conducted a physical inspection of the facility, including the living room, resident bedrooms, bathrooms, kitchen, and outdoor area. The fence and gate were observed to be in good condition. During the outdoor inspection, the LPA noted a sliding door screen and a window screen were damaged, showing evidence of rips. Additionally, damaged outdoor furniture, including chairs and a swing chair, were observed in the backyard. The Administrator was advised to dispose of these items if they are not in use. The swimming pool was found to be fenced and locked during this visit.

Inside the facility, LPA observed that the vent was missing its cover. According to S1 and Administrator, the cover fell off this morning, and a repair person is expected later today. The room temperature was recorded at 65°F. The hot water temperature in one of the bathrooms was measured at 107°F. The facility maintains a 2-day supply of perishable food and a 7-day supply of non-perishable food. The kitchen was found to be clean and sanitary. LPA also observed a locked box in the kitchen refrigerator, which, according to S1, contains medications that require refrigeration as per orders.

LPA reviewed 5 resident records. Per review of medical assessments (LIC602A), at least 2 residents in care (R1 and R2) were deemed by their physicians to be unable to leave the facility unassisted.

Deficiencies are being cited based on today's visit. Note that failure to correct deficiencies may result to civil penalties.
Exit interview was conducted with Administrator over the phone; a copy of this report and appeal rights were provided.

Stephen Richardson	TELEPHONE: (916) 263-4700
Arvin Villanueva	TELEPHONE: 916-208-0023
	DATE: 01/14/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025

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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Document Has Been Signed on 01/14/2025 01:33 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: 01/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

87205 Accountability of Licensee Governing Body: (a) The licensee, whether an individual or other entity, shall exercise general supervision over the affairs of the licensed facility and establish policies concerning its operation in conformance with these regulations and the welfare of the individuals it serves.
	Deficient Practice Statement
1 2 3 4
	POC Due Date: 01/15/2025
	Plan of Correction
1 2 3 4	Licensee to ensure there are at least 2 staff on duty between 7am and 7pm, Monday through Sunday as specified in the current stipulation order.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Stephen Richardson	TELEPHONE: (916) 263-4700
Arvin Villanueva	TELEPHONE: 916-208-0023
	DATE: 01/14/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025

LIC809 (FAS) - (06/04)

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