342700201-4-11-2024-27-AS-AVIA-D48VEU-20240411162255

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700201
Report Date: 04/11/2024
Date Signed: 04/11/2024 04:23:00 PM

Document Has Been Signed on 04/11/2024 04:23 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 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: 4	DATE:	04/11/2024
TYPE OF VISIT:	Case Management - Legal/Non-compliance	UNANNOUNCED	TIME BEGAN:	01:38 PM
MET WITH:	Tevita Kaloulasulasu, staff on duty		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	On 4/11/2024, at 1:38pm, Licensing Program Analyst (LPA) Arvin Villanueva arrived to this facility unannounced to conduct a quarterly case management visit. LPA met initially met with Tevita Kaloulasulasu, 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. Bianca gave permission to Tevita to sign this report. During this visit, there were four residents in care with two staff on duty. During this visit, LPA Villanueva conducted facility observation, reviewed four resident files, and reviewed four staff files. During facility observation, LPA observed the facility to be clean, free of clutter, sanitary and in good repair. LPA observed one outside agency caregiver assisting one resident in their room. LPA observed the stipulation order posted in a conspicuous place located in the file and medication area near the exit to the backyard. LPA observed all three exit doors to have auditory devices and they were observed to be operable and loud enough. LPA observed the room temperature to be at 73 degree F. LPA observed all three bathrooms to be clean and sanitary. Hot water temperature in one of the bathroom was measured at 114 degrees F. LPA observed medications, sharp objects, and toxic products to be properly stored, kept in safe and locked place and are inaccessible to residents in care. LPA observed all six resident bedrooms. Two of which are currently empty rooms but fully furnished and occupancy ready. All four staff files reviewed contain current first aid/CPR certificates. All four current staff are fingerprint cleared. Per interview with staff, no new admission since last quarter visit. LPA reviewed the required monthly training records as specified in the stipulation order and the following topics were conducted: 3/25/24 Personal Rights; 2/29/24 Fire Drills; 1/17/24 Medications Training. Per review of staff roster, LPA observed there are at least two caregivers on duty between 7am and 7pm, Monday through Friday. {Con't to LIC809-C...}

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) -26-4700
LICENSING EVALUATOR NAME: Arvin Villanueva	TELEPHONE: 916-558-2130
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024

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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: LOVE AND SERENITY OF ELK GROVE II	FACILITY NUMBER: 342700201
	VISIT DATE: 04/11/2024

NARRATIVE

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{...Con't from LIC809}

LPA also reviewed the facility's incident report binder. LPA observed the following incident reports:

3/22/24 - fax confirmation submitted to the Department on 3/22/24.
3/16/24 - fax confirmation submitted to the Department on 3/28/24.
2/28/24 - facility administrator/staff is unable to confirm submission to the Department during this visit.
1/13/24 - facility administrator/staff is unable to confirm submission to the Department during this visit.

Note that LPA checked the Department's incident report folder under this facility and did not find any incident reports that were submitted. Also LPA obtained copy of the above incident reports for further review. At this time, a technical violation was

At this time, per California Code of Regulations (CCR), Title 22, no deficiencies were being cited during this visit. An exit interview was held with Tevita Kaloulasulasu, and a copy of this report and appeal rights were provided.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) -26-4700
LICENSING EVALUATOR NAME: Arvin Villanueva	TELEPHONE: 916-558-2130
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024

LIC809 (FAS) - (06/04)

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