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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700201
Report Date: 09/01/2023
Date Signed: 09/01/2023 11:13:28 AM


Document Has Been Signed on 09/01/2023 11:13 AM - 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:
09/01/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Tevita KaloulasulasuTIME COMPLETED:
09:30 AM
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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. 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. No health or safety concerns observed.

Per California Code of Regulations (CCR), Title 22, no deficiencies were observed during this visit. 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: 09/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2023
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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