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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700200
Report Date: 02/11/2025
Date Signed: 02/11/2025 04:12:25 PM

Document Has Been Signed on 02/11/2025 04:12 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:		TEVITA KALOULASULASUFACILITY TYPE:
740
ADDRESS:8901 SONOMA VALLEY WAYTELEPHONE:
(916) 509-9693
CITY:SACRAMENTOSTATE: CAZIP CODE:
95829
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
02/11/2025
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:42 PM
MET WITH:Tevita KaloulasulasuTIME VISIT/
INSPECTION COMPLETED:
04:20 PM
NARRATIVE
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On 2/11/2025, Licensing Program Analyst (LPA) Arvin Villanueva arrived unannounced to this facility to conduct a case management visit. LPA met the administrator, Tevita Kaloulasulasu (AD), and stated the purpose of this visit. Present during this visit were 5 residents in care with 1 staff on duty (AD).

During a Non-Compliance Conference (NCC) meeting with Bianca Castro, 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.

During this visit, LPA observed one staff on duty which is in violation one of the Stipulation Order, which states: "(E) Respondents shall ensure that each facility with a probationary license, that retains one or more clients, who cannot leave the facility unassisted, has a minimum of two caregivers on duty between 7:00 a.m. and 7:00 p.m., Monday through Sunday. However, the facilities must, at all times, have a sufficient number of caregivers to meet the needs of the clients in care at the facilities." Per interview with licensee, Bianca Castro, she has been having difficulties with hiring new staff. Per interview with AD, this facility has been operating with one staff on duty for at least 2 weeks. Note that licensee has been cited for the same deficiency from last visit on 1/14/25.

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. The swimming pool was found to be fenced and locked during this visit. LPA observed that the damaged chairs and other damaged items noted from last visit were cleared out.




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Stephen RichardsonTELEPHONE: (916) 263-4700
Arvin VillanuevaTELEPHONE: 916-208-0023
DATE: 02/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/11/2025
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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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: 02/11/2025
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Inside the facility, LPA observed that the vent cover has been replaced. The room temperature was recorded at 68°F. The hot water temperature in one of the bathrooms was measured at 105°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, where they keep resident medications that require refrigeration.


Deficiencies are being cited based on today's visit. An immediate civil penalty is being assessed today due to repeat violation. Note that failure to correct deficiencies may result to additional civil penalties.

Exit interview was conducted with Administrator over the phone; 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: 02/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/11/2025 04:12 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: 02/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/14/2025
Section Cited
CCR
87205(a)

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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.
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Per discussion, the administrator will collaborate with the licensee, Bianca Castro, to develop a plan for hiring new staff and to ensure 2 staff are always on duty between 7am and 7pm. Plan to be submitted to the Department by POC due date.
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This requrement is not met as evidenced by:
Based on observation and interview, the licensee did not ensure there are at least 2 staff members on duty during the hours between 7am and 7pm as per stipulation orderThis poses/posed a potential health and safety risk to persons in care.
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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.
Stephen RichardsonTELEPHONE: (916) 263-4700
Arvin VillanuevaTELEPHONE: 916-208-0023

DATE: 02/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/11/2025

LIC809 (FAS) - (06/04)
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