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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 04:23:19 PM


Document Has Been Signed on 03/16/2022 04:23 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: 5DATE:
03/16/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Luisa BiuTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (s) Victoria Brown and Sarah Hurt arrived unannounced on 3/16/22 at 2:45pm to conduct a Case Management visit to obtain additional information regarding the intent to relocate the residents as the Property Owner is intending to change the use of the facility by selling it. LPAs met with Luisa Biu and stated the purpose of the visit. LPAs reviewed the residents files during this visit and deficiencies regarding facility records will be cited on a separate Case Management visit today. LPA Brown observed that the 60 day notices did not contain the required information as stated per Title 22 regulations and the Health and Safety Code.

The Licensee shall rescind the notices, revise them providing the revised notice to each resident and Community Care Licensing (CCL) as required. The notices shall include the items mentioned in Title 22 regulations 87224 (a)-(i) Eviction Procedures, and the Health and Safety Code 1569.682 Transfer of resident upon forfeiture of license or change in use of facility; duties of licensee; closure plan; duty of department upon licensee’s failure to comply; civil penalties (a)(1) - (2)(h).

In addition, the Licensee has potentially secured a relocation site. Prior to relocating the residents, upon their individual agreements as well as their responsible parties, to this location the Licensee shall be submit to the Application Unit:
· Application (LIC200)
· Application fee

· Facility sketch (LIC999)

· Evidence of control of property

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: 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)
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