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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700201
Report Date: 04/14/2022
Date Signed: 04/14/2022 02:27:09 PM


Document Has Been Signed on 04/14/2022 02:27 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 ELK GROVE IIFACILITY NUMBER:
342700201
ADMINISTRATOR:BIANCA CASTROFACILITY TYPE:
740
ADDRESS:9279 ORANGE CREST COURTTELEPHONE:
(916) 897-9287
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:6CENSUS: 6DATE:
04/14/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Bianca CastroTIME COMPLETED:
02:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christina Valerio and LPA Jamie Ivey Canady arrived unannounced to conduct a quarterly case management visit due to a current stipulation order for Love and Serenity of Elk Grove II.

LPAs toured the facility. LPAs observed the stipulation order posted on a wall and was moved to the front door during the visit. According to the stipulation order, Mike Her, Deborah Saunikalau, and Anthony Camacho are excluded and shall not be on the premises. LPAs did not observe those individuals during the visit. LPAs observed two facility staff, Staff 1 and staff 2, which were observed to be on the fingerprint clearance list and associated with Love and Serenity of Elk Grove II.

The medication cabinet was observed to be unlocked due to the lock being broken. A video recording of the door was taken by LPAs for records. Administrator Bianca stated she fixed the lock after LPAs observed the lock to be loose. The floors were observed to be sticky while LPAs were walking through the home. The couch in the living room were observed to be ripped on the corner due to the leather pealing off and had tape laid down in a X shape to cover up cuts on 3 areas of the couch. The dinning table was observed to be dirty from previous dinning services with old food crumbs and food pieces all over the table. The facility did not have a seven day supply of perishable foods and two day supply of non-perishable food. Administrator stated groceries are usually bought on Wednesday. LPA requested proof of delivery receipts from the store. Administrator stated she did not have it and will be buying groceries today. The backyard was observed to have a old washing machine, broken chairs, and old refrigerator vertically propped next to the fence on the left side of the home. Administrator Bianca stated she got a new washing machine last week. TA was provided and Administrator stated she will call Republic Services to come down to pick up the items.

Based on today's visit, deficiencies were observed and cited on LIC 809-D. Failure to correct deficiencies may result in civil penalties. Exit interview held, and a copy of the report was given to Administrator Bianca.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2022
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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Document Has Been Signed on 04/14/2022 02:27 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: LOVE AND SERENITY OF ELK GROVE II
FACILITY NUMBER: 342700201

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/15/2022
Section Cited

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87465 Incidental Medical and Dental Care (h) The following requirements shall apply...: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement was not met as evidenced by:
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Based on observations, the licensee did not ensure 1 out of 2 medications cabinets were not properly working and unable to lock, which poses an immediate health and safety risk to person in care.
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Type A
04/15/2022
Section Cited

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87555 General Food Service Requirements (b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement was not met as evidenced by:
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Based on observations, the licensee did not ensure to have a suffient amount of nonperisable foods or perishable foods at the facility, which poses an immediate 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.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 04/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 04/14/2022 02:27 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: LOVE AND SERENITY OF ELK GROVE II
FACILITY NUMBER: 342700201

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/06/2022
Section Cited

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87307 Personal Accommodations and Services (d) The following space and safety provisions shall apply to all facilities: (2)The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. This requirement was not met as evidenced by:
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Based on observation, the licensee did not ensure the furniture in the common areas were maintained in good condition. Furniture was observed to be in worn codnition and need of replacement. This poses 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.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 04/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3