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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700201
Report Date: 10/29/2024
Date Signed: 10/29/2024 01:19:41 PM

Document Has Been Signed on 10/29/2024 01:19 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/
DIRECTOR:		BIANCA CASTROFACILITY TYPE:
740
ADDRESS:9279 ORANGE CREST COURTTELEPHONE:
(916) 897-9287
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
10/29/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:Staff on duty (S1)TIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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On 10/29/24, Licensing Program Analyst (LPA) Arvin Villanueva arrived unannounced to this facility to conduct a case management visit. LPA Villanueva met with one of the staff on duty and explained the purpose of the visit. The Administrator Bianca Castro was notified of the visit and gave permission to S1 to sign this report.

Present during today's visit were 5 residents in care with 2 staff on duty (S1 and S2).
During this visit, S2 was assisting residents and S1 was doing housekeeping duties and assisting residents with their lunch.

During this visit, LPA obtained copy of resident files (R1, R2, R3, R4, R5 and R6), including their Identification and Emergency Information, current Physician Report and current Needs and Services Plan. Per Administrator, this facility is not certified Assisted Living Waiver Program at this time.

No deficiencies are being cited during today's visit.

Exit interview was conducted with S1 and a copy of this report was provided.
Stephen RichardsonTELEPHONE: (916) 263-4700
Arvin VillanuevaTELEPHONE: 916-208-0023
DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/29/2024
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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