342700491-8-5-2021-27-AS-TTRG-C5LPZA-20210805114512

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700491
Report Date: 08/05/2021
Date Signed: 08/05/2021 11:45:19 AM

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 II		FACILITY NUMBER:	342700491
ADMINISTRATOR:	RATU P VUNIMATANA		FACILITY TYPE:	740
ADDRESS:	5942 PARK VILLAGE ST		TELEPHONE:	(916) 476-5595
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95822
CAPACITY:	6	CENSUS: 6	DATE:	08/05/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Designated Administrator, Anthony Camacho		TIME COMPLETED:	12:15 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 08/05/2021 at 9:35 am, Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced to conduct an annual inspection visit. Prior to entering the facility, LPA called to ensure that the facility does not have any positive COVID-19 cases. Upon LPAs arrival, caregiver Elisha Dau was present at facility and contacted Designated Administrator, Anthony Camacho who arrived a bit later. LPA met with Designated Administrator Anthony Camacho and explained the purpose of the visit. Licensee, Javier Castro, holds current certification #6011043740 and expires on 12/12/2021. The facility is licensed to serve up to (6) six non-ambulatory residents. Approved hospice waiver for (2) two. There are currently 6 residents who reside at this facility. LPA toured the facility with Designated Administrator Anthony Camacho on 08/05/2021 at 10:25 am. LPA inspected the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms; resident bathrooms, garage, laundry area, and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA observed the facility is clean and in good repair. LPA observed sufficient furniture and lighting throughout the facility. LPA observed bedrooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition and properly maintained. The hot water temperature was observed to be 119.5 degrees Fahrenheit. Food supply is adequate for 2-day perishable and 7-day nonperishable. LPA observed knives and toxins to be locked away and inaccessible to residents. Smoke and carbon detectors were in good repair. Fire extinguisher and first aid kit was up to date. LPA checked medication storage and found medication to be locked away and inaccessible to clients. LPA also conducted the infection control domain tool. Continued on 809-C

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 II	FACILITY NUMBER: 342700491
	VISIT DATE: 08/05/2021

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The facility mitigation plan was submitted to CCLD, and it was approved on 5/16/2021. Facility has routine symptom screening checks for residents, staff, and visitors. The facility has a symptom check binder for staff, residents, and care staff. Hand Hygiene procedures have been implemented. Facility had Covid-19 posters throughout the facility, and the facility has implemented Covid-19 mitigation plan.

Administrator was informed to send updated copies of the following documents to CCL within 15 days:
(1) LIC308 Designation of Administrative Responsibility
(2) LIC500 Personnel Report
(3) Copy of Administrator Certificate
(4) LIC610 Emergency Disaster Plan
(5) Proof of Current Liability Insurance
(6) Administrative Organization (LIC309)
(7) Control of Property

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit.

Exit interview held and a copy of report given.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2021

LIC809 (FAS) - (06/04)

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