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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700881
Report Date: 01/24/2023
Date Signed: 01/24/2023 04:26:51 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 01/24/2023 04:26 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:
01/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Barbara RoseTIME COMPLETED:
04:40 PM
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Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced to conduct an annual inspection visit on 1/24/2023. LPA met with Director of Resident Services (DRS) Barbara Rose and explained the purpose of the visit. Administrator Guadalupe Ramirez was contacted and informed of LPAs purpose of today’s visit.

Administrator holds current certification # 6035691740, expiration date:7/12/2023. The adult day program is licensed to serve up to 15 residents at any given time. A resident can stay in care of the facility for up to 30 days at any given time. During the resident’s stay the resident will have full use of the facility services. There were no residents in care during today's Annual visit.

The facility has one floor with 52 rooms, all for memory care. There are two dining areas, 1 large activity area and two medication rooms, and two living rooms. The facility also has a laundry room and janitorial room. LPA observed the facility is clean and in good repair. LPA observed sufficient furniture and lighting throughout the facility. Smoke and carbon detectors were in good repair. Fire extinguishers and first aid kits were up to date.

The following forms and documents were requested to be submitted within 15 days:
(1) LIC 610 Emergency Disaster Plan
(2) Proof of Current Liability Insurance

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE: DATE: 01/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2023
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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