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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700201
Report Date: 01/11/2024
Date Signed: 01/11/2024 01:31:04 PM


Document Has Been Signed on 01/11/2024 01:31 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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:
01/11/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Bianca Castro, AdministratorTIME COMPLETED:
01:30 PM
NARRATIVE
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On 1/11/2024, at 10:15am, Licensing Program Analyst (LPA) Arvin Villanueva arrived to this facility unannounced to conduct a case management visit. LPA met initially met with a staff on duty, and explained the purpose of the visit, which was to ensure compliance with the current stipulation order and Title 22 regulations. The administrator on record, Bianca Castro, was made aware of this visit and arrived shortly after. During this visit, there were 5 residents in care with 2 staff on duty.

During this visit, LPA conducted facility observation, 6 resident file reviews and 2 staff file reviews. LPA observed the facility to be clean, safe, sanitary and in good repair at the time of this visit. The stipulation order has been posted in a conspicuous location. The two staff present upon arrival were observed to be fingerprint cleared with current CPR and First Aid certificate of completion. LPA is unable to review monthly staff training as specified in the stipulation order. Per interview with the administrator, there is no record of the required monthly staff training but informed LPA that the administrator will start to keep a record of the monthly staff training per stipulation order. LPA confirmed that individuals who are excluded from the facility were not present during the inspection. Auditory devices on exits doors were observed to be in working condition. When doors were opened, an alarm sound went off in a loud manner for the front door, exit doors, and backyard door. Medications and toxic products were observed to be properly stored, locked, and inaccessible to residents in care. A technical advisory was provided for licensee to obtain PRN Authroization Letter from each of resident's physician. During medication review, LPA did not observe resident files to contain PRN Authorization Letter. A technical advisory was provided for licensee to request a waiver granted to permit non-physicians to sign medical assessment as observed in 1 of 5 resident during resident file review.

Per California Code of Regulations (CCR), Title 22, deficiencies were observed during this visit. An exit interview was held with Bianca Castro, and a copy of this report and appeal rights were provided.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) -26-4700
LICENSING EVALUATOR NAME: Arvin VillanuevaTELEPHONE: 916-558-2130
LICENSING EVALUATOR SIGNATURE:
DATE: 01/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/11/2024
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 01/11/2024 01:31 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: LOVE AND SERENITY OF ELK GROVE II
FACILITY NUMBER: 342700201

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/18/2024
Section Cited
CCR
87205(a)

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87205 Accountability of Licensee Governing Body: (a) The licensee, whether an individual or other entity, shall exercise general supervision over the affairs of the licensed facility and establish policies concerning its operation in conformance with these regulations and the welfare of the individuals it serves.
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Licensee to maintain a record of monthly staff training as specified in the current stipulation order.

Licensee to submit a statement of understanding of the current stipulation order to the Department by POC due date.
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This requrement is not met as evidenced by:
Based on record review and interview, the licensee could not provide to LPA a record of monthly staff training as per stipulation order. This poses/posed a potential health and safety risk to persons in care.
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Licensee to submit a proof of this month's (January 2024) proof of staff training as specified in the current stipulation order to the Department by the POC due date.

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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) -26-4700
LICENSING EVALUATOR NAME: Arvin VillanuevaTELEPHONE: 916-558-2130
LICENSING EVALUATOR SIGNATURE:
DATE: 01/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/11/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2