<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700201
Report Date: 05/12/2023
Date Signed: 05/12/2023 03:24:59 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 - IncidentUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Facility StaffTIME COMPLETED:
03:30 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
Licensing Program Analyst (LPA) Christina Valerio arrived to the facility unannounced to conduct a case management due to receiving notification of an incident that occurred on 05/11/2023. LPA met with facility staff, and explained the purpose of the visit.

On 05/11/23, Licensee Bianca contacted LPA Valerio at 9:59 AM. According to the licensee, resident 1 (R1) was sent to the hospital on 05/11/2023 due to not being at baseline. Licensee/Administrator Bianca also inquired about night supervision for her care home. According to records review, House Policies state "Our staff is available to respond to emergencies on a 24-hour bases. For health emergencies, our policy is to call 911 immediately..." On the morning of 05/11/23, R1 pressed the call button and staff did not respond due to sleeping and not hearing the alarm. R1 called 911 to be taken to the hospital. Staff were awaken when paramedics arrived to the home at 4:00 AM. Paramedics did not take R1 during this time; however, staff observed the resident to be off baseline later during morning breakfast and was sent to the hospital for observation. Records show that the two staff on shift are scheduled to work 05/10/23 and 05/11/23 from 7:00 AM - 7:00 PM. According to interviews, staff were checking on the resident at 8:00 PM and then hourly from 10:00 PM - 3:30 AM before falling asleep on the couch. Staff stated R1 refused to go to the hospital each time staff checked on R1.

In an e-mail sent to LPA on 05/11/23, Licensee Bianca stated she currently does not have any residents with dementia that meet that requirement as specified in Title 22 and therefore the live-in care staff are on-call and do not need to be awake. Based on file review, it is determined that the facility administrator is required to have one (1) awake staff on shift during over night shift. Resident files show that 3 out 6 residents are with dementia symptoms.
According to an interview with an outside agency, the facility did not have an admission agreement to give to residents and there is no night supervision for residents. LPA reviewed all resident files and found an admission agreement inside each file. LPA provided technical assistance to have licensee purchase ink and paper should anyone need copies of documents.
Continues on LIC 809 - C...
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 4


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: 05/12/2023
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
26
27
28
29
30
31
32
Continued from LIC 809

According to staff interviews, 2 residents are currently out in the hospital and 4 residents are in the home. According to staff interviews, there are 0 residents that are diagnosis with dementia symptoms, diabetic, on hospice, or anyone with a special diet. It was revealed later that staff offer residents sugar free alternatives and sugar free drinks.

LPA reviewed resident records and obtain a copy for future reference. LPA reviewed resident files and observed 3 out of 6 residents have a dementia listed on the LIC 602 and/or appraisal, 2 residents to have a special diet, and 0 residents on hospice.

During review of resident records, LPA found 1 resident file to be missing their TB result.

LPA requested the following copies of documentation be sent to LPA by no later than 05/14/23 at 5:00 PM. LIC 500 from January, Updated LIC 500 for May 2023, and Staff schedule for January 2023 - June 2023.

Per California Code of Regulations (CCR) - Title 22, deficiencies were observed during the visit. Citations can be found on LIC 809 -D. Appeal Rights provided. Failure to correct deficiencies may result in civil penalties. An exit interview was held with facility staff and licensee, and a copy of the report was provided. LPA spoke to Licensee/Administrator via phone.
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
LIC809 (FAS) - (06/04)
Page: 2 of 4
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)
Deficiency Dismissed
Type A
05/13/2023
Section Cited
CCR
87705(c)(4)(A)

1
2
3
4
5
6
7
87705 Care of Persons with Dementia (c) Licensees...shall...ensuring the following: (4)There is an adequate number of direct care staff to support each resident’s ...safety and health care needs...(A) shall have at least one night staff person awake and on duty...This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee stated administrator will implement a care staff to be awake during night shift and ensure the staff will be awake. LPA to receive a copy of the LIC 500 and staff schedule by POC due date.
8
9
10
11
12
13
14
Based on records review and interviews, live-in care staff worked 12 hours, worked on-call and were expected to work another 12 hour shift. While staff were sleeping, R1 had a medical emergency and pressed the call light, which staff did not hear due to sleeping. This poses an immediate health and safety risk to resident's in care.
8
9
10
11
12
13
14
Request Denied
Type A
05/13/2023
Section Cited
CCR87465(a)(2)

1
2
3
4
5
6
7
87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed..by compliance with the following: (2) The licensee shall provide assistance in meeting necessary medical and dental needs...This requirement was not met as evidenced by:

1
2
3
4
5
6
7
Licensee stated Administrator and staff will review Title 22 87465, review all resident Needs and Services plan/LIC 602, and send a letter to LPA by POC due date stating acknowledgement of all care plans.
8
9
10
11
12
13
14
Based on records review, the licensee did not ensure 2 out of 6 resident's special diet were followed as directed by their care plan. This poses an immediate health and safety risk or residents in care.
8
9
10
11
12
13
14
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)
Page: 3 of 4


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 B
05/26/2023
Section Cited
CCR
87458(b)(1)

1
2
3
4
5
6
7
87458 Medical Assessment (b) The medical assessment shall include..(1)... results of an examination for communicable tuberculosis...This requirement was not met as evidenced by
1
2
3
4
5
6
7
Licensee stated administrator will have resident complete the TB test. LPA to receive results or proof of scheduled appointment by POC due date.
8
9
10
11
12
13
14
Based on records review, 1 out of 6 resident files did not have TB test results on file. The file had pending results on LIC 602. This poses a potential health and safety risk to residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7
8
9
10
11
12
13
14
8
9
10
11
12
13
14
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)
Page: 4 of 4