342700492-8-26-2021-27-AS-KHOS-C6EMLH-20210831094221

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700492
Report Date: 08/26/2021
Date Signed: 08/26/2021 01:39:24 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/25/2021 and conducted by Evaluator Victoria Brown

COMPLAINT CONTROL NUMBER: 27-AS-20210825112116

FACILITY NAME:	LOVE AND SERENITY III		FACILITY NUMBER:	342700492
ADMINISTRATOR:	JULIE NONU		FACILITY TYPE:	740
ADDRESS:	573 SHAW RIVER WAY		TELEPHONE:	(916) 469-9145
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95831
CAPACITY:	6	CENSUS: 0	DATE:	08/26/2021
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Julie Nonu		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Facility is dirty and blinds are broken

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) arrived unannounced to conduct an investigation of the above mentioned allegations on 8/26/21 at 10:15am. LPA was met by Julie Nonu and the purposes of the visit was discussed.

LPA toured the physical plant. There are no residents residing in the home at this time. LPA observed dusty tables and a blind in the kitchecn and bedroom #2 that was broken.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 9099D during this visit. Civil penalties shall be assessed when the licensee fails to correct the violation to Health and Safety Code Section 1569.605 following any appropriate extensions to the plan of correction due date. The Licensee was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted with Julie Nonu and a copy of this report was provided.

Substantiated

Estimated Days of Completion: 30

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20210825112116

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 III	FACILITY NUMBER: 342700492
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/26/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/01/2021 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	Maintenance and Operation The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.	1 2 3 4 5 6 7	Licensee shall submit a receipt for replacing the blinds and a letter of confirmation that the home has been cleaned and disinfected by POC due date.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: LPA used fingers to rub across the tables and there was a film of dust observed and pictures were taken of the two broken blinds. Based on observation facility did not fix the blinds or ensure the facility was cleaned and disinfected. This poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2021

LIC9099 (FAS) - (06/04)

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