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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700201
Report Date: 08/09/2022
Date Signed: 08/09/2022 12:23:20 PM


Document Has Been Signed on 08/09/2022 12:23 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:
08/09/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Facility StaffTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Christina Valerio arrived to the facility unannounced to conduct a case management visit. LPA Valerio met with facility staff, and explained the purpose of the visit. Administrator Bianca Castro was informed of visit and gave facility staff permission to sign on her behalf.

On 05/10/22, an incident occured at the facility. A resident went to sit at the dinning table for lunch. Once the resident sat down, the chair broke, causing the resident to fall. According to staff interviews and facility records, staff immediately called 911. The licensee/administrator informed the responsible party and Community Care Licensing within hours of the incident. The resident was transported to the hospital where it was learned the resident sustained a wrist fracture. The facility replaced all chairs to ensure no other incident occur. Since the incident, the resident has been going to follow-up appointments, physical therapy, and is doing better.


Per California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed during this visit. An exit interview was held, and a copy of the report was given to Administrator Bianca Castro.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2022
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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