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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700492
Report Date: 01/20/2022
Date Signed: 01/20/2022 12:11:17 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 IIIFACILITY NUMBER:
342700492
ADMINISTRATOR:JULIE NONUFACILITY TYPE:
740
ADDRESS:573 SHAW RIVER WAYTELEPHONE:
(916) 469-9145
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY:6CENSUS: 4DATE:
01/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Laisana RakumaTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required Annual visit on 1/20/22 at 11:15AM. LPA met with Laisana Rakuma, Caregiver, and stated the purpose of todays visit.

LPA toured and inspected the physical plant to ensure there are no safety hazards to residents.

LPA observed 4 residents and 1 caregiver during this visit.

The temperature inside the facility was observed to be at 75*F which is within the required range of 68-85*F. The hot water temperature was measured at 106*F during this visit which is within the required range of 105-120*F. LPA observed fire extinguisher(s), smoke and carbon monoxide detectors, and central heating and air in the facility. LPA observed 2-day perishables and 7-day non-perishables.

LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide.


Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited. An exit interview was conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:

DATE: 01/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2022
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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