<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700828
Report Date: 09/20/2024
Date Signed: 09/20/2024 04:59:40 PM


Document Has Been Signed on 09/20/2024 04:59 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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: 5DATE:
09/20/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:51 PM
MET WITH:Staff on duty (S1)TIME COMPLETED:
05:10 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 9/20/2024, at 4:51 pm, Licensing Program Analyst (LPA) Arvin Villanueva arrived at this facility unannounced to conduct a case management visit and return a resident (R1)'s file. LPA met with staff on duty (S1) and explained the purpose of the visit. The Administrator, Bianca Castro, was made aware of this visit and gave permission for S1 to sign this report. Today’s visit there were 5 residents in care with 1 staff on duty (S1).

On 9/19/24, this facility was visited by this LPA and requested to remove R1's file for the purpose of copying relevant documents at the Regional Office. Administrator was made aware of this request. During this visit, LPA Villanueva returned R1’s file and was received by S1.

Per California Code of Regulations, Title 22, no citations were issued during this visit. An exit interview was held with S1a nd a copy of this report was provided.

SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Arvin VillanuevaTELEPHONE: 916-208-0023
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1