342700201-9-11-2024-27-AS-AVIA-D8ZRJA-20240911130336

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700201
Report Date: 09/11/2024
Date Signed: 09/11/2024 01:03:56 PM

Document Has Been Signed on 09/11/2024 01:03 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: 6	DATE:	09/11/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Staff on duty (S1)		TIME COMPLETED:	01:00 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 9/11/2024, at 9:30am, Licensing Program Analyst (LPA) Arvin Villanueva arrived to this facility unannounced to conduct their required annual inspection visit. LPA met initially met with staff on duty (S1), and explained the purpose of the visit. The administrator on record, Bianca Castro, was made aware of this visit and gave permission to S1 to assist this LPA and sign this report. During this visit, there were 6 residents in care with 2 staff on duty. LPA toured the facility to ensure compliance with Title 22 regulation. Upon arrival, residents were having their breakfast. One staff was preparing food and other staff on duty was assisting other residents with their hygiene. Outside area was observed to be free of obstructions. Fence was observed to be in good repair at this time. The side gate was observed to be dragging when LPA opened it. Technical assistance was provided to licensee for the repair. According to S1, repair was scheduled this coming Friday (9/13/24). LPA observed the temperature inside the facility was measured at 72F. The hot water was measured at 118F in one bathroom. Facility maintain 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 to be locked and inaccessible to residents. During the inspection of the kitchen, LPA observed cleaning materials and sharp objects stored under-the-sink to be accessible to residents in care. The doors under-the-sink storage were observed to be locked but the small door to the left was observed to be connected to the under-the-sink storage and was observed to not have a lock. (Photo was taken). LPA requested S1 to remove all the cleaning materials and scissors/knives stored under the sink and S1 stored them in a locked closet near the front entrance. LPA informed S1 to not store chemicals and sharp objects under the sink until they put a lock on the small door connected to the under-the-sink storage. Resident rooms were observed to be sanitary, good repair 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 4/5/2024.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Arvin Villanueva	TELEPHONE: 916-208-0023
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024

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: 09/11/2024

NARRATIVE

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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 eating, listening to music, talking with staff, watching television, and reading. One resident went out to the community with an outside agency staff. LPA reviewed 4 staff and 6 resident files. Staff files were observed to be up to date with current training. Resident files were complete with necessary documentation. Facility does not manage resident money. Disaster/fire drills are conducted at least quarterly.

LPA requested the following documentation be sent to LPA by end of business day on 09/12/24: LIC 500, LIC 308, Liability Insurance.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies were observed during this visit. Note that failure to correct citations will result in civil penalties.

An exit interview was held, and a copy of the report was provided.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Arvin Villanueva	TELEPHONE: 916-208-0023
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 09/11/2024 01:03 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: 09/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. During the inspection of the kitchen, LPA observed cleaning materials and sharp objects stored under-the-sink to be accessible to residents in care. The doors under-the-sink storage were observed to be locked but the small door to the left was observed to be connected to the under-the-sink storage and was observed to not have a lock. (Photo was taken) which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/12/2024
	Plan of Correction
1 2 3 4	Corrected during this visit: Staff on duty (S1) removed all cleaning chemicals, scissors, and knives out of the under-the-sink storage and placed them in the locked closet near the front entrance. If licensee continues to use the under the sink storage to store cleaning chemicals and sharp objects, they must place a lock to the small door and submit photo to the Department.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Richardson	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Arvin Villanueva	TELEPHONE: 916-208-0023
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024

LIC809 (FAS) - (06/04)

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