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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700491
Report Date: 10/01/2021
Date Signed: 10/01/2021 10:52:31 AM

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: 4DATE:
10/01/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator, Anthony CamachoTIME COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analyst (LPA) Tung Truong arrived at the facility unannounced to conduct a case management visit regarding the complaint control # 27-AS-20210819120128. Upon LPAs arrival, caregiver Elisha Dau was present at facility and contacted Administrator, Anthony Camacho who arrived a bit later. LPA met with Administrator Anthony Camacho and explained the purpose of the visit.

On complaint control # 27-AS-20210819120128, the allegation: Resident wandered away from the facility was substantiated but was not cited on the complaint's LIC 9099-D. The deficiency for the allegation above is cited on today’s case management visit on LIC 809-D. In addition, 87411(a) Personnel Requirements - General was previously cited on 9/17/2021, therefore, a civil penalty shall be assessed in the amount of $250 for a repeat violation within a 12- month period during this visit.

In addition, LPA is reciting the facility for 87405(a) Administrator - Qualifications and Duties. The facility did not provide the Department with proof of administrator certificate for Designated Administrator, Anthony Camacho. A valid administrator certificate is required in order to update the facility profile on Licensing system.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies were cited during this visit.

An exit interview was held and a copy of this report, LIC 809-D, LIC 421FC and appeal rights was provided to Administrator Anthony Camacho.

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

DATE: 10/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2021
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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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: 10/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/04/2021
Section Cited

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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:
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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.
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Licensee shall provide CCL with a written declaration stating that he/she has read and understands the Title 22 Regulations by 10/4/2021.
Type A
10/04/2021
Section Cited

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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:
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Based reviewed record, the facility did not provide the Department with a valid administrator certificate for designated administrator, Anthony Camacho. This posed an Immediate, Health, Safety or Personal Rights risk to residents in care.
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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: 10/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/01/2021
LIC809 (FAS) - (06/04)
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