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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700491
Report Date: 11/22/2024
Date Signed: 11/22/2024 12:01:07 PM

Document Has Been Signed on 11/22/2024 12:01 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:LOVE AND SERENITY IIFACILITY NUMBER:
342700491
ADMINISTRATOR/
DIRECTOR:		WAQALALA, UNAISIFACILITY TYPE:
740
ADDRESS:5942 PARK VILLAGE STTELEPHONE:
(916) 476-5595
CITY:SACRAMENTOSTATE: CAZIP CODE:
95822
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 4DATE:
11/22/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Temo OkomatebulaTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced case management visit
on 11/22/2024. This visit is to confirm ORDERS TO INDIVIDUAL FOR IMMEDIATE EXCLUSION FROM ALL
FACILITIES.

LPA met with caregiver Temo Okomatebula and stated the purpose of visit. Facility understands this is an
Immediate Exclusion effective 11/21/2024 and S1 is excluded and 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.
Therefore, the Department orders the facility to remove S1 from any contact with clients and not allow this
employee to be physically present in the facility.

Exit interview conducted, a copy of this report provided on this date. A signature on these forms
acknowledges receipt of these forms.
Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
Kevin GouldTELEPHONE: (619) 672-5924
DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2024
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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