342700201-12-15-2020-27-AS-ATUK-BWC2N5-20201215163210

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700201
Report Date: 12/15/2020
Date Signed: 12/15/2020 04:33:07 PM

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 II		FACILITY NUMBER:	342700201
ADMINISTRATOR:	BIANCA CASTRO		FACILITY TYPE:	740
ADDRESS:	9279 ORANGE CREST COURT		TELEPHONE:	(916) 897-9287
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95624
CAPACITY:	6	CENSUS: 6	DATE:	12/15/2020
TYPE OF VISIT:	Case Management - Licensee Initiated	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Bianca Castro		TIME COMPLETED:	04:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Unannounced Pre-licensing visit made via Facetime out to this facility on 12/15/2020 and was met by the Administrator Bianca Castro, who was briefly interviewed by LPA Anthony Tuck and LPA Eric Stone. It was learned that this facility will be licensed to serve up to (6) residents non ambulatory at any given time. This Applicant was also seeking a program for dementia care and a hospice waiver to accept and retain up to (1) hospice residents at any given time. There were 6 residents in care during today's Pre-licensing visit due to a change in ownership. Tour of the facility was conducted via Facetime. Dining area, living area, and all other areas intended for resident use were toured and observed to be furnished and maintained in compliance at this time. Kitchen area was toured. Cabinets and drawers were opened and reviewed by LPA Tuck and LPA Stone along with the Applicant. Knives and other sharp utensils were observed to be locked in a cabinet to make them inaccessible to the residents at all times. Food supply for 2-day perishable and 7-day nonperishable quantities were reviewed to make sure that this facility was in compliance at this time. Medication cabinet, located in the hallway area, was toured. First aid kit was observed to be present and contained all required components at this time. A tour of the (6) private resident bedrooms was conducted. It was observed that 1 resident bedroom was equipped with a direct exit at this time. Furnishings and furniture intended for use by the residents were observed to be sufficient and able to meet the needs of the residents at this time. A tour of the resident bathrooms was conducted. Hot water temperatures were taken and measured to make sure that they were within the allowed range of 105-120 degrees. Grab bars and nonskid mats were observed to be present and in compliance at this time. Laundry area was toured. All cleaning agents and detergents were observed to be locked and made inaccessible at this time. Continued on 809c...

SUPERVISOR'S NAME: Krystall Moore	TELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Anthony Tuck	TELEPHONE: (916) 708-6203
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2020

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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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
	VISIT DATE: 12/15/2020

NARRATIVE

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Linen closet, located in the hallway, was observed to contain a sufficient supply of towels and linens able to meet the needs of the residents at this time.
A tour of the exterior grounds was conducted. A review of the facility perimeter fence, side gates, and walkways were observed to be maintained in compliance at this time. Gate latches were reviewed and observed to be functional and allowed access for emergency response. All proper posters were posted on walls. All smoke detectors were operational, and the carbon monoxide detector was operational.

There were 0 deficiencies observed during today's Pre-licensing visit.

Component III interview was conducted with the Applicant and completed during today's Pre-licensing visit.

Exit Interview

A copy of this report will be emailed to the address of the applicant. The applicant is to print and sing a copy and send back to CCL.

SUPERVISOR'S NAME: Krystall Moore	TELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Anthony Tuck	TELEPHONE: (916) 708-6203
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2020

LIC809 (FAS) - (06/04)

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