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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700491
Report Date: 07/01/2026
Date Signed: 07/03/2026 08:58:15 AM

Document Has Been Signed on 07/03/2026 08:58 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 IIFACILITY NUMBER:
342700491
ADMINISTRATOR/
DIRECTOR:		WAQALALA, UNAISIFACILITY TYPE:
740
ADDRESS:5942 PARK VILLAGE STTELEPHONE:
(916) 476-5595
CITY:SACRAMENTOSTATE: CAZIP CODE:
95822
CAPACITY: 6CENSUS: 6DATE:
07/01/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Luisa BiuTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Avelina Martinez and Sulma Lopez arrived at this facility unannounced on July 01, 2026, at 9:30 AM to conduct a case management visit. LPAs met with Luisa Biu and explained the purpose of the case management visit.

The purpose of the visit today, is in response to learned Incidental medical and dental and basic services deficiencies. Based on four out of five interviews it was indicated that there is one non-awake staff during the night shift. Resident 2 (R2) reported during one night incident, they required a brief change. R2 reported they had to scream for assistance, however, the night staff on duty did not respond. R2 reported they had to wear a soiled brief until a family member arrived at the facility the next day in the morning. Resident 3 (R3) reported that resident 4 (R4) fell while they were in the restroom at night. R4 was yelling for assistance, however the staff on duty did not respond to R4's yelling. R3 reported the staff on duty was not awake at the time of the incident. Resident 1 (R1) and resident 5 (R5) both reported that the night staff is not awake, and they have to yell from their bedroom when they need care and assistance. Both R1 and R5 reported that night staff does not respond to them when they yell for help and care assistance.

LPA Lopez conducted a medication administration record (MAR) review for R1. R1's MAR was missing the following medication entries: Budesonide Formoterol 80 inhaler entry, Doxycycline Hyclate 100 MG, and Benzonatate 200 MG Capsul. It is unknown if facility staff have been administering these medications. It was also learned that the facility does not have prescription orders or discontinuation orders for these medications.

Continued...

NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Avelina Martinez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/01/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 II
FACILITY NUMBER: 342700491
VISIT DATE: 07/01/2026
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R4 has medication prescription orders for the following medication: Carboxymethylellulose 0.5%, brimodine 0.2%, dorzolamide 2 %, Latanoprost 0.005%, Pantoprazole 40 MG EC Tab, Sulfamenthoxazole 400MG/80MG Tab. However, the facility does not have a supply of the medications. The medication orders are a result of a June 02, 2026 medical appointment. R4 has a prescription order Budesonide/Formoterol 160 mcg, and the facility has a supply of the medication. However, the medication is not listed on R4's MAR, and it is unknown if R4 is being administered the medication. It was also learned that R4's Prednisone 5MG is not being administered as ordered. The Prednisone medication bottle states,"Take 5 tablets by mouth once a day., start taking 25 MG daily on August 05, 2025, decrease dose by 5 MG every week." The pill supply started at 105 tablets and as of July 01, 2026, there are 54 pills left. As a result, facility staff are not administering the medication as ordered.

As a result, of this visit, the following deficiencies were cited per Title 22 Regulations: 87464(f)(1) Basic Services Basic services and 87465(a)(4) Incidental Medical and Dental. The deficiencies can be found on the 809-D Page.

An exit interview was conducted, and a copy of the 809 Report, 809-D Page, and Appeals Rights document were provided to the facility.

NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Avelina Martinez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/03/2026 08:58 AM - It Cannot Be Edited


Created By: Avelina Martinez On 07/01/2026 at 11:57 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: LOVE AND SERENITY II
FACILITY NUMBER: 342700491

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/01/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/02/2026
Section Cited
CCR
87464(f)(1)

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87464(f)(1) Basic Services Basic services shall at a minimum include:Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidence by: Based on interviews and file reviews, the Licensee did not ensure
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Facility staff agrees to email signal system and awake night schedule plan by 07/02/2026. Facility staff agrees to implement a signall system, and to have an awake staff that can meet the residents' needs at night.
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residents needs were being met during the night shift. This posed an immediate health and safety risk to residents in care.
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Facility staff agrees to email LIC 500 Personnel Report and singal system purchase receipt and pictures of installed signal system. By July 14, 2026 5:00 PM.
Type B
07/14/2026
Section Cited
CCR87465(a)(4)

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87465(a)(4) Incidental Medical and Dental Care: A plan for incidental medical and dental care shall be developed by each facility...The licensee shall assist residents with self administered medications as needed. This requirement was not met as evidence by: based on file review and interviews, the
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Facility staff agrees to conducted a medication audit by my a medical professional by POC date July 14, 2026. Medication audit documentation shall be emailed to LPA Martinez by POC date July 14, 2026 by 5:00 PM.
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licensee did not ensure facility staff were assisting R4 with their medication management and administration.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM MANAGER:
Avelina Martinez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/01/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2026


LIC809 (FAS) - (06/04)
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