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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700492
Report Date: 03/16/2022
Date Signed: 03/16/2022 03:57:09 PM


Document Has Been Signed on 03/16/2022 03:57 PM - It Cannot Be Edited

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:
03/16/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Facility Caregiver, Luis Biu TIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analysts (LPA's) Sarah Hurt and Victoria Brown arrived at the facility unannounced on March 16, 2022 at 02:45 p.m. to conduct a subsequent Case Management visit. LPA's met with facility Caregiver Luisa Biu and explained the purpose for today's visit.

LPA's reviewed resident files for five facility residents. The resident files were deemed incomplete as they were missing information and/or signatures and dates as required on the licensing documents.

The following deficiency was cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with facility Caregiver Luis Biu and a copy of this report along with appeal rights was provided.




SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/16/2022
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 2


Document Has Been Signed on 03/16/2022 03:57 PM - It Cannot Be Edited

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 III
FACILITY NUMBER: 342700492

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/23/2022
Section Cited

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87506(a) Resident Records.(a)The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement has not been met as evidenced by:
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Based on record review LPA's reviewed five resident files of which had missing, dates and signatures which poses a potential 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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 03/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/16/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2