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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700828
Report Date: 07/18/2023
Date Signed: 07/18/2023 12:44:52 PM


Document Has Been Signed on 07/18/2023 12:44 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: DATE:
07/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Omar SlypherTIME COMPLETED:
12:50 PM
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Licensing Program Analyst (LPA) Christina Valerio arrived to the facility unannounced to conduct an annual required inspection. LPA met with facility staff and explained the purpose of the visit. Administrator Bianca designated facility staff to conduct the annual with LPA.

LPA toured the physical plant to ensure compliance with Title 22 regulations. LPA observed resident bedrooms, bathroom, common areas, laundry room, staff area, and outdoor areas. Resident bedrooms were observed to have necessary furniture and furnishings. No emergency exits were obstructed. Bathrooms were observed to have soap, paper towels, hand rails, and trash cans. Common areas were clean and organized with furniture in good condition. Technical Assistance was provided for a used protective bed pad that was located on the couch in the living room. According to staff, a resident sits on the pad and got up for lunch.

LPA observed the temperature inside the facility was measured at 76*F, which is within the required range of 68 degrees F and 85 degrees F. Hot water temperature in the bathrooms were measured at 115.4*F degrees. Facility was observed to have 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 Valerio observed a fire extinguisher, smoke and carbon monoxide detectors, central heating and air in the facility. Resident files were observed to be up to date with necessary assessments and care plans. LPA observed hospice nurses and home health visiting the facility. Residents were observed with a visitor, taking a nap, people watching outside, doing word puzzles, and watching television. Facility staff were assisting residents, assisted with visitors needs, and preparing lunch. Lunch today was tuna salad sandwiches and fruit.

LPA requested the following documentation be sent to LPA: LIC 500, LIC 308, LIC 610D, Liability Insurance

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed or cited. An exit interview was held and copy of report given to facility staff.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2023
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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