<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700491
Report Date: 10/14/2021
Date Signed: 10/14/2021 12:08:21 PM

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 IIFACILITY NUMBER:
342700491
ADMINISTRATOR:RATU P VUNIMATANAFACILITY TYPE:
740
ADDRESS:5942 PARK VILLAGE STTELEPHONE:
(916) 476-5595
CITY:SACRAMENTOSTATE: CAZIP CODE:
95822
CAPACITY:6CENSUS: 4DATE:
10/14/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Anthony CamachoTIME COMPLETED:
12:30 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 10/14/2021 at 11:00 am, Licensing Program Analyst (LPA) Tung Truong arrived at the facility unannounced to conduct a POC visit in regard to deficiencies cited on complaint CONTROL NUMBER 27-AS-20210819122759 and Control Number 27-AS-20210819120128 that were not cleared. Upon LPAs arrival, caregiver Elisha Dau was present at facility and contacted Administrator Unaisi Waqalala. LPA met with facility staff Anthony Camacho and explained the purpose of today’s visit. The purpose of today’s visit is to clear the remaining deficiencies on the complaints below.

The remaining deficiencies for complaint CONTROL NUMBER 27-AS-20210819122759

*Deficiency cited under Title 22 Regulation 87411(c) – Cleared. Proof of correction was submitted on 10/13/2021. Civil penalty is $100.00 per day until verified. Civil Penalty for four days at $100.00 per day for four days from 9/28/21 - 10/1/21 is total $400.00. Civil penalty in the amount of $400 was issued on 10/1/2021. Civil Penalty for seven days at $100.00 per day for seven days from 10/2/21 - 10/8/21 is total $700.00. Civil penalty in the amount of $700 was issued on 10/8/2021. Civil Penalty for five days at $100.00 per day for five days from 10/9/21 - 10/13/21 is total $500.00. Civil penalty in the amount of $500 was issued on today’s visit.


Report continued on 809-C
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
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: 10/14/2021
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
26
27
28
29
30
31
32
*Deficiency cited under Title 22 Regulation 87211(a)(2) – Cleared. Proof of correction was submitted on 10/13/2021. Civil penalty is $100.00 per day until verified. Civil Penalty for four days at $100.00 per day for four days from 9/28/21 - 10/1/21 is total $400.00. Civil penalty in the amount of $400 was issued on 10/1/2021. Civil Penalty for seven days at $100.00 per day for seven days from 10/2/21 - 10/8/21 is total $700.00. Civil penalty in the amount of $700 was issued on 10/8/2021. Civil Penalty for five days at $100.00 per day for five days from 10/9/21 - 10/13/21 is total $500.00. Civil penalty in the amount of $500 was issued on today’s visit.

The remaining deficiencies for complaint Control Number 27-AS-20210819120128

*Deficiency cited under Title 22 Regulation 87468(a)(1) – Cleared. Proof of correction was submitted on 10/13/2021. Civil penalty is $100.00 per day until verified. Civil Penalty for four days at $100.00 per day for four days from 9/28/21 - 10/1/21 is total $400.00. Civil penalty in the amount of $400 was issued on 10/1/2021. Civil Penalty for seven days at $100.00 per day for seven days from 10/2/21 - 10/8/21 is total $700.00. Civil penalty in the amount of $700 was issued on 10/8/2021. Civil Penalty for five days at $100.00 per day for five days from 10/9/21 - 10/13/21 is total $500.00. Civil penalty in the amount of $500 was issued on today’s visit.

Total civil penalties issued $1500.

Exit interview was held with Anthony Camacho, a copy of this report, LIC 421FCs, letter of deficiency citations cleared and appeal rights were provided.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2