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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700828
Report Date: 05/03/2022
Date Signed: 05/03/2022 01:11:27 PM


Document Has Been Signed on 05/03/2022 01:11 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 OF ELK GROVE IIIFACILITY NUMBER:
342700828
ADMINISTRATOR:CASTRO, BIANCAFACILITY TYPE:
740
ADDRESS:9442 MAZATLAN WAYTELEPHONE:
(916) 585-5483
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:6CENSUS: 4DATE:
05/03/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Lusiana BulameicabaiTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 5/3/22 at 1:00pm. This visit is to confirm ORDERS TO INDIVIDUAL FOR IMMEDIATE EXCLUSION FROM ALL FACILITIES.

LPA was met by Lusiana Bulameicabai , Caregiver and stated the purpose of the visit. LPA spoke with Administrator Bianca Castro who stated S1 never worked at this 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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