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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700201
Report Date: 12/22/2022
Date Signed: 12/22/2022 02:40:24 PM


Document Has Been Signed on 12/22/2022 02:40 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: 5DATE:
12/22/2022
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
01:24 PM
MET WITH:Denise De La VegaTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christina Valerio arrived to the facility unannounced to conduct a case management visit. LPA met with facility staff, and explained the purpose of the visit, which was to ensure compliance with the current stipulation order and Title 22 regulations.

LPA observed two staff present upon arrival. Both staff were observed to be fingerprint cleared and had updated training for 2022. Auditory devices on exits doors were observed to be in working condition. When doors were opened, an alarm sound went off.

Staff are aware of reporting requirement procedures in the even of an elopement, AWOL, fall, or unusual incident. LPA has recently been sent two death reports and two incident reports, all of which were reported within 7 business days.

Medication cabinet, sharps, and toxic products were locked away and stored properly. The stipulation order has been posted in a conspicuous location. LPA confirmed that individuals who are excluded from the facility were not present during the inspection.

LPA conducted a walk through of the facility with facility staff. LPA observed resident's watching television, eating a snack, having a family visit, taking a nap, and engaging with staff. Staff were observed cleaning rooms, cleaning the kitchen, making dinner, and assisting residents. Facility was observed to have non-perishable food items for a minimum of 2 days and perishable food items for 7 days. Facility staff stated they are having prime rib for Christmas.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed during this visit. An exit interview was held with facility staff, and a copy of the report was left for Administrator Bianca Castro.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 12/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/22/2022
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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