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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700201
Report Date: 10/18/2021
Date Signed: 10/18/2021 12:55:30 PM

Document Has Been Signed on 10/18/2021 12:55 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
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: 6DATE:
10/18/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Mereoni RakulaTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Case Management visit on 10/18/2021 at 12:30pm to inquire if there is an excluded person presently working in the facility. LPA met with Mereoni Rakula, Designated person in charge and stated the purpose of the visit which is due to a Decision and Order effective 10/18/21.

LPA spoke with Bianca Castro regarding a person that should be excluded from licensed facilities. Bianca Castro stated that the person has not been working or been present in the facility in over 1 year. Bianca Castro requested that Mereoni Rakula sign report and be given the documents for todays visit.

To date, LPA found that the person in question is still associated to the facility according to a facility roster dated 10/15/21. The Administrator shall remove the person's association from the facility as of todays date.

LPA provided Mereoni Rakula with a copy of the Order to Individual of Immediate Exclusion From All Facilities. LPA informed Mereoni Rakula and Bianca Castro this person is not allowed to be employed and/or on the facility premises.

The Order to Individual of Immediate Exclusion From All Facilities came into effect as of 10/18/2021.

The facility understands this is an Immediate Exclusion and has agreed this person cannot be allowed to work, live in, and/or have contact with clients in any residential facility licensed by the California Department of Social Services unless otherwise ordered by the Department.

Per California Code of Regulations, Title 22 Division 6, Chapter 8, no deficiencies were cited. Exit interview held, A Copy of report given.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE: DATE: 10/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/18/2021
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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