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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700886
Report Date: 12/22/2020
Date Signed: 12/22/2020 03:00:30 PM

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, THEFACILITY NUMBER:
342700886
ADMINISTRATOR:TBDFACILITY TYPE:
740
ADDRESS:9750 LAGUNA SPRINGS DRIVETELEPHONE:
(916) 209-0735
CITY:ELD GROVESTATE: CAZIP CODE:
95757
CAPACITY:70CENSUS: 0DATE:
12/22/2020
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator Ricky David Jr.TIME COMPLETED:
03:00 PM
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Announced Pre-licensing visit was made by LPA’s Jason Lund and Eric Stone via Zoom on 12/22/2020 with Administrator Ricky David Jr, Caleb Perkins and Don Barber from Corprate.

The facility will be licensed to serve up to 70 residents at any given time. There were no residents in care during today's Pre-licensing visit.

Tour of the facility was conducted via Zoom. 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.

A tour via Zoom was conducted of the memory care facility. Observed were the three different type of bedrooms for residents, kitchen area, dining areas, laundry room and janitorial room were viewed and are in compliance at this time.

The Facility has two Medication rooms that are locked and secured along with the first aid kits. Medication room contained all required components at this time. The facility has five fire extinguishers (EXP-10/13/21) placed throughout the facility.

There were no deficiencies observed during today's Pre-licensing visit.
LPA Lund completed Component 111 requirements with the facility.

Report will be emailed for signature and emailed back to LPA Lund
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2020
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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