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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700828
Report Date: 01/23/2025
Date Signed: 01/23/2025 11:30:42 AM

Document Has Been Signed on 01/23/2025 11:30 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:LOVE AND SERENITY OF ELK GROVE IIIFACILITY NUMBER:
342700828
ADMINISTRATOR/
DIRECTOR:
CASTRO, BIANCAFACILITY TYPE:
740
ADDRESS:9442 MAZATLAN WAYTELEPHONE:
(916) 585-5483
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 4DATE:
01/23/2025
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Omar SlypherTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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On 1/23/2025, Licensing Program Analyst (LPA) Arvin Villanueva arrived unannounced at this facility to conduct a case management visit. LPA met with staff on duty, Omar Slypher, and stated the purpose of the visit. The administrator, Bianca Castro, was notified of the visit and gave permission to Omar to sign this report. Present during this visit were 4 residents in care with 1 staff on duty.

Case Management Visit - Health Checks
During today’s visit, LPA conducted a physical tour of the facility. Upon arrival, LPA observed one resident in the family room watching squirrels play on the fence and interacting with LPA. Other residents were in their bedrooms. The room temperature was noted to be 76°F, and the hot water temperature in one hallway bathroom was measured at 115°F. The kitchen was found to be clean and in good repair, and food supplies appeared to be adequate. LPA also reviewed the files of 2 residents, including their admission agreements, needs and services plans, medical assessments, and ambulatory statuses. LPA noted that no new admissions have occurred since the Non-Compliance Conference (NCC) on 11/6/24, with the most recent admission being on 10/25/24. At present, no residents are receiving hospice services, and the bedrooms are being used appropriately according to the residents' ambulatory clearance.

Case Management Visit - Death Report

Death report stated that resident (R1) passed away of natural causes. Additionally, R1 was receiving hospice services. Prior to this, R1 was hospitalized on 10/9/2024 due to unwitnessed fall occurred at this facility which resulted in wound on the face and hospitalization. Per interview with facility staff, Omar, after hospitalization, R1 was discharged to a skilled facility for rehabilitation. Interview with Omar revealed that after being discharged from skilled facility, R1 returned to this facility on hospice care. R1 was on hospice care until their death. Death report was received timely on 12/23/2024. Copy of death report, incident report and discharge document from skilled facility was obtained.

Exit interview was conducted with Omar and a copy of this report was provided.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE: DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/23/2025
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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