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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700200
Report Date: 05/03/2022
Date Signed: 05/03/2022 03:26:41 PM


Document Has Been Signed on 05/03/2022 03:26 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: 6DATE:
05/03/2022
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Walesi VakararawaTIME COMPLETED:
03:35 PM
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On 5/3/22 at 1:50PM Licensing Program Analyst (LPA) Chris Hopkins arrived unannounced to conduct a quarterly Case Management inspection due to a current stipulation order. LPA was met by staff Walesi Vakararawa, and stated the purpose of the inspection.

Todays 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.

Licensee was previously informed that CCL shall receive copies of the notifications to all residents and/or responsible parties and that civil penalties could be assessed if licensee fails to follow the requirements. LPA observed a copy of the notifications signed by residents and observed posting of the stipulation.

LPA toured and inspected the physical plant to ensure there are no safety hazards to residents. LPA observed 6 residents and 2 caregivers during this visit, who are fingerprint cleared. The hot water temperature was measured at 108*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 2-day perishables and 7-day non-perishables. 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 (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited. An exit interview was conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2022
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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