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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700492
Report Date: 05/03/2022
Date Signed: 05/03/2022 11:15:24 AM


Document Has Been Signed on 05/03/2022 11:15 AM - 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:
05/03/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Julie NonuTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 5/3/22 at 11:00am. This visit is to confirm ORDERS TO INDIVIDUAL FOR IMMEDIATE EXCLUSION FROM ALL FACILITIES.

LPA was met by Julie Nonu and stated the purpose of the visit. Administrator stated S1 does not work in the facility. S1 was not present at the time of visit.

Facility understands this is an Immediate Exclusion effective 4/14/2022. S1 is excluded and prohibited from being a licensee, owning a beneficial ownership of 10% interest or more in a licensed facility, or being an Administrator, officer, director, member, or manager of a licensee or entity controlling a licensee. S1 cannot be allowed to work, live in, and/or have contact with clients in any residential facility licensed by the California Department of Social Services.

Per California Code of Regulations, Title 22 Division 6, Chapter 8, no deficiencies were observed and cited. Exit interview held, Copy of report given
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2022
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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