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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700201
Report Date: 12/13/2024
Date Signed: 12/13/2024 04:17:11 PM

Document Has Been Signed on 12/13/2024 04:17 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:		TEVITA KALOULASULASUFACILITY TYPE:
740
ADDRESS:9279 ORANGE CREST COURTTELEPHONE:
(916) 897-9287
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 5DATE:
12/13/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:40 PM
MET WITH:Tevita KaloulasulasuTIME VISIT/
INSPECTION COMPLETED:
04:25 PM
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On 12/13/24, Licensing Program Analyst (LPA) Arvin Villanueva arrived unannounced to this facility to conduct a case management visit for the purpose of issuing a civil penalty for the citation given on 11/6/2024 for to the complaint # 27-AS-20240806163340. LPA met with the facility administrator, Tevita Kaloulasulasu and stated the purpose of this visit. The licensee, Bianca Castro, was also informed of the purpose of this visit. Present during today’s visit were 5 residents in care with 2 staff on duty.

An immediate civil penalty in the amount of $500 was assessed for the violations of Health and Safety Code 1569.50(a)(3). When the complaint findings were delivered on 11/6/24 , the licensee was informed that an enhanced civil penalty (ECP) was pending review and may be assessed according to Health and Safety Code 1569.49(f). Once civil penalty assessments have been determined, the Department will return at a future date to assess the civil penalties.

Exit interview was conducted with Tevita Kalaulasulasu. A copy of this report (LIC809) and LIC421M were provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE: DATE: 12/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/13/2024
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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