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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700201
Report Date: 05/12/2023
Date Signed: 05/12/2023 03:24:12 PM


Document Has Been Signed on 05/12/2023 03:24 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:
05/12/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
07:45 AM
MET WITH:Facility StaffTIME COMPLETED:
09:24 AM
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.

The stipulation order has been posted in a conspicuous location. LPA observed two staff present upon arrival. Both staff were observed to be fingerprint cleared and had updated training for 2023. Auditory devices on exits doors were observed to be in working condition. When doors were opened, an alarm sound went off for the front door, exit doors, and backyard door.Staff are aware of reporting requirement procedures in the event of an elopement, AWOL, fall, or unusual incident. LPA was informed on 05/11/23 by the facility administrator of an incident that occurred on 05/11/23. Medication cabinet, sharps, and toxic products were locked away and stored properly. LPA confirmed that individuals who are excluded from the facility were not present during the inspection.

LPA spoke to residents and staff during the visit. 1 resident was observed to be eating breakfast, which was a cup of coffee, avocado, pancakes, fruit, and cereal with milk. LPA observed the facility food supply. LPA did not observe a food supply adequate to meet the minimum requirement of 7 days of non-perishables and 2 days of perishables. Staff stated the food order is scheduled to come today. Facility staff provided LPA a confirmation of food delivery for 11:19 AM on 05/12/2023. Hot water was measured at 118.9*F in the common area bathroom, which is within the regulatory range of 105-120*F.

Per California Code of Regulations (CCR), Title 22, deficiencies were observed during this visit. Appeal rights provided. An exit interview was held, and a copy of the report provided.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 05/12/2023 03:24 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: 05/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/13/2023
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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Licensee stated the food is scheduled to arrive at 05/13/23 at 11:19AM. Licensee to send LPA pictures of food in pantry, food in refrigerator, and food in the freezer along with a copy of the receipt to LPA by POC due date.
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Based on observations, the licensee did not ensure to have a sufficient amount of non-perishable 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: 05/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2023
LIC809 (FAS) - (06/04)
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