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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700881
Report Date: 01/13/2022
Date Signed: 01/13/2022 04:33:18 PM

Document Has Been Signed on 01/13/2022 04:33 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:GARDENS AT LAGUNA SPRINGS MEMORY CARE ADP, THEFACILITY NUMBER:
342700881
ADMINISTRATOR:DAVID, JR., RICKYFACILITY TYPE:
775
ADDRESS:9750 LAGUNA SPRINGS DRIVETELEPHONE:
(916) 667-3167
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY: 15CENSUS: 0DATE:
01/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:Heather AshbyTIME COMPLETED:
04:45 PM
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On 1/13/2022 at 3:20 pm, Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced to conduct an annual inspection visit. LPA met with Regional Director of Operation Heather Ashby explained the purpose of today’s visit.

Administrator holds current certification #6033977740 and expires on 2/2/2023. There are currently no clients reside at this facility.

LPA inspected the physical plant including but not limited to the common area, dining area, resident bedrooms; resident bathrooms, medication room and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA observed the facility is clean and in good repair. LPA observed sufficient furniture and lighting throughout the facility. LPA observed bedrooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition and properly maintained. Hot water measured were within the required range of 105-120 degrees Fahrenheit. Fire extinguishers and first aid kit were up to date. LPA also conducted the infection control domain tool.

The facility mitigation plan was submitted to CCLD, and it was approved on 6/17/2021. Facility has digital sign-in/screening system for residents, staff, and visitors. Hand Hygiene procedures have been implemented. Facility had Covid-19 posters throughout the facility, and the facility has implemented Covid-19 mitigation plan.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were cited during this visit. Exit interview was held and a report was given.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE: DATE: 01/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/13/2022
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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