342700491-2-3-2025-27-AS-KGOD-DDJV43-20250203150541

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700491
Report Date: 02/03/2025
Date Signed: 02/03/2025 03:05:57 PM

Document Has Been Signed on 02/03/2025 03:05 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 II		FACILITY NUMBER:	342700491
ADMINISTRATOR/ DIRECTOR:	WAQALALA, UNAISI		FACILITY TYPE:	740
ADDRESS:	5942 PARK VILLAGE ST		TELEPHONE:	(916) 476-5595
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95822
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 4	DATE:	02/03/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:50 PM
MET WITH:	Mere Racule		TIME VISIT/ INSPECTION COMPLETED:	03:30 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 1/3/25 at 12:50pm Licensing Program Analyst (LPA) Kevin Gould arrived at Love and Serenity II for the purpose of conducting a required 1 year annual inspection. LPA met with staff, Mere Racule and together conducted a tour of the home. LPA and staff evaluated the physical plant to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms; resident bathrooms, living and dining room and outdoor areas. LPA observed the facility to be free of odor, clean and in good repair. LPA observed that all rooms are equipped with the required furniture. LPA did observe several rooms in the home to have lighting that was not functioning as designed including the laundry room, resident bathroom, bedroom and hallway lights. LPA measured the water temperature, temperature measured at 118 degrees F which meets the 105-120 degree Fahrenheit regulation. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA notes the facility had the required carbon monoxide detectors. First aid kit was checked and is complete. LPA observed centrally stored medications secure from residents. LPA reviewed staff and resident files. LPA observed one staff member present did not have a completed health screening report or TB clearance. LPA observed the training records to be incomplete and the training materials do not meet requirements in terms of care of persons with dementia as the training did not consist of enough training hours to meet regulations. Per California Code of Regulations, Title 22 the following deficiencies are cited during today's inspection. An exit interview was conducted and a copy of this report and appeal rights were left at the facility.

Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
Kevin Gould	TELEPHONE: (619) 672-5924
	DATE: 02/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2025

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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Document Has Been Signed on 02/03/2025 03:05 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 II	FACILITY NUMBER: 342700491
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87411(f)

Personnel Requirements - General

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in one out of three staff files reviewed which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/04/2025
	Plan of Correction
1 2 3 4	Facility will provide a written plan of correction indicating all steps for new hires including training and health screenings to meet all title 22 regulations for new hires and will ensure staff members have a health screening by the POC due date.

Section Cited

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
Kevin Gould	TELEPHONE: (619) 672-5924
	DATE: 02/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/03/2025 03:05 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 II	FACILITY NUMBER: 342700491
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87303(d)

Maintenance and Operation

(d) There shall be lamps or light appropriate for the use of each room and sufficient to ensure the comfort and safety of all persons in the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above in several areas of the home including but not limited to resident bedrooms, bathrooms, front porch and hallways which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/14/2025
	Plan of Correction
1 2 3 4	Licensee has a greed to ensure all light fixtures have a working light bulb and are operational.

Type B

Section Cited

HSC

1569.625(b)(2)

Other Provisions

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on staff file review, the licensee did not comply with the section cited above for all staff members. LPA observed staff training identified does not meet minimum regulations for persons with dementia and did not appropriately identify the training and hours and qualifications of the trainer which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/14/2025
	Plan of Correction
1 2 3 4	Licensee has agreed to submit an updated staff training plan for new hires and annual training requirements including the type of training, the trainers qualifications, actual hours trained, training subject matter and documentation of completion.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
Kevin Gould	TELEPHONE: (619) 672-5924
	DATE: 02/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2025

LIC809 (FAS) - (06/04)

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