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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700828
Report Date: 08/02/2022
Date Signed: 08/02/2022 04:34:35 PM


Document Has Been Signed on 08/02/2022 04:34 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:
08/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Administrator Bianca CastroTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Jason Lund arrived at the above address unannounced to conduct an annual/required inspection. LPA Lund met with facility staff and stated the purpose of today’s visit. LPA Lund later met with Administrator Bianca Castro. Census 4 residents.

LPA Lund and Administrator Bianca Castro toured the facility inside and outside to ensure the safety of the residents and compliance with Title 22 regulations. LPA observed the facility to be clean and clear from obstructions. Resident bedrooms was furnished with necessary furniture. LPA observed the facility to have a first aid kit, hand washing signage, and COVID-19 informational signage posted at the front door and throughout the facility. The facility is able to dedicate a COVID-19 bathroom and bedroom if needed.

LPA observed the temperature inside the facility was measured at 75 *F, which is within the required range of 68 degrees F and 85 degrees F. Facility has nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. LPA observed the centrally stored medications area to be locked and inaccessible to clients. LPA Lund observed a fire extinguisher with last check on 07/7/2022, smoke and carbon monoxide detectors, central heating, and air in the facility.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed or cited. Exit interview held and copy of report given to via telephone with Administrator Bianca Castro
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2022
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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