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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700491
Report Date: 09/17/2021
Date Signed: 09/17/2021 02:35:00 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: 5DATE:
09/17/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Assistant Administrator, Una WaqalalaTIME COMPLETED:
03:00 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 09/17/2021 at 1:30 PM, Licensing Program Analyst (LPA) Tung Truong conducted a plan of correction (POC) visit in relation to a citation issued on 9/2/2021. LPA met with Assistant Administrator Una Waqalala and explained the purpose of the visit.

Proof of correction was submitted to LPA Truong via email on 9/13/2021 by Administrator Anthony Camacho. The files attached to the email was corrupted and was not readable.

*Deficiency cited under Title 22 Regulation 87411(a) and 87405(a) are extended to 9/20/21. Citation issued on 9/2/2021 will be recited on today's visit on the LIC809-D.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 809-D during this visit. Civil penalties shall be assessed when the licensee fails to correct the violation and any appropriate extensions to the plan of correction due date.

Exit interview held with Assistant Administrator Una Waqalala , a copy of the report and LIC809-D was provided.

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

DATE: 09/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2021
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/20/2021
Section Cited

1
2
3
4
5
6
7
87411(a) Personnel Requirements-General. Personnel shall at all times be sufficient in numbers and competent to provide the services necessary to meet resident needs.

This requirement is not met as evidenced by:
8
9
10
11
12
13
14
Based on records and LPA’s observation, the facility did not have an adequate number of staff working in the care facility. The facility has multiple incidents of residents’ AWOL from the facility. This posed an Immediate, Health, Safety or Personal Rights risk to residents in care.
8
9
10
11
12
13
14
Type A
09/20/2021
Section Cited

1
2
3
4
5
6
7
87405(a) Administrator – Qualifications and Duties. All facilities shall have a certified administrator with enough freedom from other responsibilities and a sufficient number of hours on the premises to give adequate attention to the administration of the facility.

This requirement is not met as evidenced by:
8
9
10
11
12
13
14
Based on records and LPA’s observation, the facility did not have adequate Administrator oversight. During LPA's visit, no Licensee/ administrator in facility was present in the facility to assist LPA with the visit. This posed an Immediate, Health, Safety or Personal Rights risk to residents in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:
DATE: 09/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2