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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700881
Report Date: 01/16/2024
Date Signed: 01/16/2024 01:03:43 PM

Document Has Been Signed on 01/16/2024 01:03 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: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:
01/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:47 AM
MET WITH:RAMIREZ, GUADALUPETIME COMPLETED:
01:20 PM
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct an annual required inspection. LPA met with Administrator Guadalupe Ramirez, and explained the purpose of the visit.

The Day Program is located inside the Facility, Gardens at Laguna Springs Memory Care. The Day Program is licensed for up to 15 individuals. According to the Administrator, there are currently 0 participants; however, the licensees have plans to utilize the day program in the future.

Administrator currently holds an Administrator Certificate #6035691740 and is waiting for the Department to send her renewal certificate.

LPA Valerio and Administrator toured the facility to ensure compliance with Title 22 regulations. The area that will be utilized for Day Program is located in the center of the facility. Participants will have access to the common areas and dinning areas. LPA did not observe any health, safety, or personal rights risk concerns during the tour.

LPA obtained Administrator information to update the Regional Office system. Administrator Ricky David Jr. is no longer the administrator.

Per California Code of Regulations (CCR) - Title 22, Division 6, no deficiencies were observed during today's visit. An exit interview was held, and a copy of the report was provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 01/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/16/2024
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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