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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700491
Report Date: 04/26/2022
Date Signed: 04/26/2022 10:20:45 AM


Document Has Been Signed on 04/26/2022 10:20 AM - 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 IIFACILITY NUMBER:
342700491
ADMINISTRATOR:UNAISI WAQALALAFACILITY TYPE:
740
ADDRESS:5942 PARK VILLAGE STTELEPHONE:
(916) 476-5595
CITY:SACRAMENTOSTATE: CAZIP CODE:
95822
CAPACITY:6CENSUS: 6DATE:
04/26/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Susana Masiwala TIME COMPLETED:
10:25 AM
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to the facility to conduct a case management for the purpose of delivering an Order to Licensee/Facility of Immediate Exclusion From Facility. LPA Valerio met with facility staff Susana Masiwala and explained the purpose of today's visit. Facility staff called Administrator Unaisi Waqalala, which designated staff to sign for her. LPA explained the letter over the phone to Administrator Unaisi.

LPA Valerio handed the Order to Licensee/Facility of Immediate Exclusion from Facility Letter to facility staff and explained Staff 1 (S1) has been excluded and must be removed from any contact with clients and may not be physically present in any facility.

No deficiencies were observed during the visit. A declaration of service was completed for the visit. An exit interview was held, and a copy of the report was left at the facility.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2022
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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