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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 11:13:47 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:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Tevita KaloulasulasuTIME COMPLETED:
11:30 AM
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Licensing Program Analysts (LPA) Christina Valerio arrived at this facility unannounced to conduct an annual inspection visit. LPA Valerio was met by facility staff Tevita Kaloulasulasu, and explained the purpose of the visit.

LPA toured the facility to ensure compliance with Title 22 regulation. Upon arrival, LPA saw an outside contractor doing maintenance on the outside of the home. According to facility staff, the contractor will be doing maintenance inside and outside of the facility for the next couple weeks. LPA observed the temperature inside the facility was measured at 74*F. The hot water was measured at 114.1*F. Facility has nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. An emergency supply of food was observed. LPA observed the centrally stored medications area and cleaning supplies to be locked and inaccessible to clients. Resident rooms was sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguisher is up to date with last check on 05/24/2023.

LPA spoke to residents and staff during the visit. LPA observed staff assisting a resident with an health visitor, obtaining items for a resident, prompting resident's for morning ADLs, assisting residents with ADLs, cleaning, and preparing food items for residents. Residents were observed sleeping, eating, listening to music, talking with staff, watching television, and reading. LPA reviewed 4 staff and 3 resident files. Staff files were observed to be up to date with current training. Resident files were complete with necessary documentation.
LPA requested the following documentation be sent to LPA by 09/07/23: LIC 500, LIC 308, LIC 610D, Liability Insurance

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 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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