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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700491
Report Date: 10/08/2021
Date Signed: 10/08/2021 04:06:49 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: 4DATE:
10/08/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Una WaqalalaTIME COMPLETED:
04:30 PM
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On 10/8/2021, Licensing Program Analyst (LPA) Tung Truong arrived at the facility unannounced to conduct a POC visit in regard to deficiencies cited on a case management visit on 10/1/2021 and deficiencies for complaint CONTROL NUMBER 27-AS-20210819122759 and Control Number 27-AS-20210819120128 that were not cleared. Upon LPAs arrival, caregiver Elisha Dau was present at facility and contacted Unaisi Waqalala who arrived a bit later. LPA met with facility staff Unaisi Waqalala and explained the purpose of the visit.

The following deficiencies were cited a case management visit on 10/1/2021.

*Deficiency cited under Title 22 Regulation 87411(a) – Cleared. The facility did not submitted proof of correction by due date. Proof of correction was submitted on 10/6/21. Civil Penalty for two days at $100.00 per day for two days is total $200.00. Civil penalty in the amount of $200 was issued.

*Deficiency cited under Title 22 Regulation 87405(a) – Cleared. The facility did not submitted proof of correction by due date. Proof of correction was submitted on 10/6/21. Civil Penalty for two days at $100.00 per day for two days is total $200.00. In addition, a civil penalty of $250 is assessed for repeated violation. Civil penalty in the amount of $450 was issued.

Report continued on 809-C
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2021
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 3
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: 10/08/2021
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The following deficiencies were cited under complaint CONTROL NUMBER 27-AS-20210819122759

*Deficiency cited under Title 22 Regulation 87411(c) – Not cleared. The civil penalty of $400 was issued on 10/1/2021. At this time the facility has not submitted proof of correction of training registration for staff. Civil penalty is $100.00 per day until verified. Civil Penalty for seven days at $100.00 per day for seven days from 10/2/21 - 10/8/21 is total $700.00. Civil penalty in the amount of $700 was issued.

*Deficiency cited under Title 22 Regulation 87633(d) - Cleared. The civil penalty of $400 was issued on 10/1/2021. Proof of correction was submitted on 10/6/2021. Civil penalty is $100.00 per day until verified. Civil Penalty for five days at $100.00 per day for five days from 10/2/21 - 10/8/21 is total $500.00. Civil penalty in the amount of $500 was issued.

*Deficiency cited under Title 22 Regulation 87211(a)(2) – Not cleared. The civil penalty of $400 was issued on 10/1/2021. At this time the facility has not submitted proof of correction. Civil penalty is $100.00 per day until verified. Civil Penalty for seven days at $100.00 per day for seven days from 10/2/21 - 10/8/21 is total $700.00. Civil penalty in the amount of $700 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 civil penalty of $400 was issued on 10/1/2021. At this time the facility has not submitted proof of correction of training registration for staff. Civil penalty is $100.00 per day until verified. Civil Penalty for seven days at $100.00 per day for seven days from 10/2/21 - 10/8/21 is total $700.00. Civil penalty in the amount of $700 was issued.

Report continued on 809-C
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: 10/08/2021
NARRATIVE
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Total civil penalties issued $3,050.

An exit interview was held, a copy of this report, LIC 421FCs and appeal rights were provided to Unaisi Waqalala.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3