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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700886
Report Date: 07/26/2022
Date Signed: 07/26/2022 12:09:16 PM


Document Has Been Signed on 07/26/2022 12:09 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, THEFACILITY NUMBER:
342700886
ADMINISTRATOR:MARY KEATONFACILITY TYPE:
740
ADDRESS:9750 LAGUNA SPRINGS DRIVETELEPHONE:
(916) 667-3167
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY:70CENSUS: 30DATE:
07/26/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Stephen Sarine, Administrator Designee
Kirk Goodin, Acting Executive Director		TIME COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tung Truong arrived at the facility unannounced to conduct a case management visit on 07/26/2022 at 10:15 am. LPA met with Acting Executive Director, Kirk Goodin and Administrator Designee, Stephen Sarine and explained the purpose of the visit.

The purpose of the visit today is to address the issues learned during a separate complaint investigation. It was learned that the facility doesn’t have a diabetic diet menu. Moreover, there was no Diabetic Care Plan available upon LPA request for review.

During today’s visit, LPA observed the Diet and Nutrition Care Manual and reviewed care plan of five diabetic residents. It was learned that the facility doesn't have a specific menu for diabetic diet. Diabetic diet are followed by guideline from the Diet and Nutrition Care Manual and Diabetic protocols.

Based upon documentation reviewed and received, no violations or deficiencies have been issued during today's visit. An exit interview was conducted with Designee, Stephen Sarine and a copy of this report was provided.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2022
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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Document Has Been Signed on 07/26/2022 12:09 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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, THE
FACILITY NUMBER: 342700886

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
06/28/2022
Section Cited

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Diabetes. In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following…Providing modified diets as prescribed by a resident's physician as specified in Section 87555(b)(7). This requirement is not met as evidence by:
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Based on interviews and record reviews, the Licensee did not ensure a diabetic menu is in place. Facility has five diabetics residents. LPA s observed no Diet Menu regarding this matter. This poses a potential health and safety risk to residents in care.
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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.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2022
LIC809 (FAS) - (06/04)
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