342700201-8-5-2020-27-AS-VBRN-BS7P62-20200805110139

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700201
Report Date: 08/05/2020
Date Signed: 08/05/2020 11:01:54 AM

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 ELK GROVE II		FACILITY NUMBER:	342700201
ADMINISTRATOR:	SAUNIKALOU, DEBORAH		FACILITY TYPE:	740
ADDRESS:	9279 ORANGE CREST COURT		TELEPHONE:	(916) 897-9287
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95624
CAPACITY:	6	CENSUS: 5	DATE:	08/05/2020
TYPE OF VISIT:	Office	ANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Javier Castro and Bianca Castro		TIME COMPLETED:	11:00 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	An informal conference was conducted today in the Sacramento Regional Office via Microsoft Teams. The purpose of this informal conference meeting is to discuss the high volume of complaints/ inability to remain in substantial compliance with the regulations/or specific incident that has occurred in the last 2 years. Present in the meeting is Licensing Program Manager(s) Stephenie Doub and Liza King, Licensing Program Analyst (s) Victoria Brown and Anthony Tuck, and Javier Castro and Administrator Bianca Castro representatives of Love And Serenity Of Elk Grove LLC. The informal conference process was explained during this meeting. The facility was licensed on 10/19/2017, for a capacity of 6 Non-Ambulatory residents of which 1 may be bedridden. Since licensure the facility was cited 5 Type A and 3 Type B violations in 2018. In 2019, the facility was cited 4 Type A and 2 Type B violations. The facility has also been cited 3 Type A and 1 Type B violations for complaints and received civil penalties in the amount of $250.00. A review of the facility file revealed that the facility has cleared all Plan of Corrections (POC) for citations and paid the civil penalties that were assessed.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2020

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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: LOVE AND SERENITY OF ELK GROVE II	FACILITY NUMBER: 342700201
	VISIT DATE: 08/05/2020

NARRATIVE

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Issues discussed during the meeting were:
· The amount of complaint's filed against this facility within the last 24 months
· Change of LLC/Change of Administrator-New Application needed-No Notification of 100% change to CCL
· Physical Plant-Hazards present
· Food storage-Open Containers
· Incidental Medical and Dental- Calling 911
· Criminal Record Clearance-Staff not Associated
· False Claims-Records changed
· Restricted Health Condition-Unstageable Pressure Injury
· Medications-unlocked, injections
· Resident Records-Appraisals
· Maintenance and Operation-Hot water
· Licensee/Administrator accountability for all licensed facilities
· Covid-19 status- Review PINs-Notifications to CCL
· TSP services for assistance offered-Declined by representatives
· Increased Quarterly Visits to be conducted
· Next Steps based on continued deficiencies-Non-Compliance/Administrative Action

The facility has stated they will do the following to achieve continued and substantial compliance:
· Increase the amount of training each staff receives
· Submit new application documents with fee
· Submit documentation for Administrator certificate to LPA A. Tuck
· Create policies and procedures to ensure facility physical plant is in compliance
· Develop Plan and submit regarding visitation policy

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, An exit interview was conducted with Javier Castro and Bianca Castro via Microsoft Teams and a copy of this report was provided via email and an electronic email read receipt confirms receiving these documents.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2020

LIC809 (FAS) - (06/04)

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