342700491-10-1-2021-27-AS-TTRG-C7DQKJ-20211001121426

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700491
Report Date: 10/01/2021
Date Signed: 10/01/2021 12:14:30 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 II		FACILITY NUMBER:	342700491
ADMINISTRATOR:	RATU P VUNIMATANA		FACILITY TYPE:	740
ADDRESS:	5942 PARK VILLAGE ST		TELEPHONE:	(916) 476-5595
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95822
CAPACITY:	6	CENSUS: 4	DATE:	10/01/2021
TYPE OF VISIT:	POC	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Administrator, Anthony Camacho		TIME COMPLETED:	01:00 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 10/1/2021, Licensing Program Analyst (LPA) Tung Truong arrived at the facility unannounced to conduct a POC visit in regard to deficiencies cited on 9/24/2021 for complaint CONTROL NUMBER 27-AS-20210819122759 and Control Number 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. The following deficiencies were cited under complaint CONTROL NUMBER 27-AS-20210819122759 Deficiency cited under Title 22 Regulation 87411(c) - not cleared. The facility has not submitted proof of correction. Civil penalty is $100.00 per day until verified. Civil Penalty for four days at $100.00 per day for four days is total $400.00. Civil penalty in the amount of $400 was issued. Deficiency cited under Title 22 Regulation 87633(d) - not cleared. The facility has not submitted proof of correction. Civil penalty is $100.00 per day until verified. Civil Penalty for four days at $100.00 per day for four days is total $400.00. Civil penalty in the amount of $400 was issued. Report continued on 809-C

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (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
	VISIT DATE: 10/01/2021

NARRATIVE

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*Deficiency cited under Title 22 Regulation 87211(a)(2) - not cleared. The facility has not submitted proof of correction. Civil penalty is $100.00 per day until verified. Civil Penalty for four days at $100.00 per day for four days is total $400.00. Civil penalty in the amount of $400 was issued.

The following deficiencies were cited under complaint Control Number 27-AS-20210819120128

*Deficiency cited under Title 22 Regulation 87468(a)(1) - not cleared. The facility has not submitted proof of correction. Civil penalty is $100.00 per day until verified. Civil Penalty for four days at $100.00 per day for four days is total $400.00. Civil penalty in the amount of $400 was issued.

*Deficiency cited under Title 22 Regulation 872(a)(1)(D) - cleared. Licensee complied with the terms of the POC by POC due date.

Total civil penalties issued $1,600.

Exit interview conducted with Administrator Anthony Cacacho, a copy of this report, LIC 421FCs and appeal rights were provided.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (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

LIC809 (FAS) - (06/04)

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