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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700491
Report Date: 08/11/2023
Date Signed: 08/11/2023 03:33:25 PM


Document Has Been Signed on 08/11/2023 03:33 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 IIFACILITY NUMBER:
342700491
ADMINISTRATOR:WAQALALA, UNAISIFACILITY TYPE:
740
ADDRESS:5942 PARK VILLAGE STTELEPHONE:
(916) 476-5595
CITY:SACRAMENTOSTATE: CAZIP CODE:
95822
CAPACITY:6CENSUS: 4DATE:
08/11/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Adi Lina TuilomaTIME COMPLETED:
03:50 PM
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On 8/11/23, Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced to conduct a health and safety check. LPA met with Assistant Administrator Adi Lina Tuiloma and explained the purpose of the visit.

The purpose of the visit today is in response to Administrator Unaisi Waqalala request for licensing forms to change facility administrator on 7/27/23. It was learned during today’s visit that Unaisi Waqalala is still the facility administrator at this time. Administrator Unaisi advised that she will submit the request for change of administrator once all the paperwork is completed.

LPA briefly toured the physical plant to ensure compliance with Title 22 regulations. There are currently 4 residents who reside at this facility. There were two staff present during today's visit. LPA observed the facility to be clean and sanitary. LPA observed an adequate supply of food for 4 residents. The temperature inside was set to 78 degrees Fahrenheit. LPA observed the fire extinguisher(s) and first aid kits were up to date. LPA observed centrally stored medications, toxins, and sharp knives kept locked and inaccessible to residents.

No deficiencies were observed pursuant to Title 22 rules and regulations, Health and Safety Codes.

Exit interview was conducted, and a copy of this report was provided to the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2023
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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