342700886-10-5-2022-27-AS-TTRG-CJWUVT-20221005155541

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700886
Report Date: 09/30/2022
Date Signed: 10/05/2022 03:55:50 PM

Document Has Been Signed on 10/05/2022 03:55 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, THE		FACILITY NUMBER:	342700886
ADMINISTRATOR:	STEPHEN SARINE		FACILITY TYPE:	740
ADDRESS:	9750 LAGUNA SPRINGS DRIVE		TELEPHONE:	(916) 667-3167
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95757
CAPACITY:	70	CENSUS: 30	DATE:	09/30/2022
TYPE OF VISIT:	Case Management - Legal/Non-compliance	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Kirk Goodin, Executive Director Steve Sarine, Administrator		TIME COMPLETED:	11:40 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	A Non-Compliance Conference was held via Microsoft Teams on September 30, 2022 at 10:00 AM. The Department explained the purpose of this office meeting to the Licensee/Administrator of Gardens at Laguna Springs Memory Care. The following were in attendance: Regional Manager (RM) Stephenie Doub, Licensing Program Manager (LPM) Czarrina Camilon-Lee, Licensing Program Analyst (LPA) Tung Truong, VP of Operation Michelle Baker, Executive Director Kirk Goodin, Administrator Steve Sarine, Regional Nurse Heather Ashby and facility representatives: Cyndie Bryant, Mary Keaton, and attorney, Joel Goldman. The purpose of today's conference is to discuss the facility non-compliance issues. The Non-Compliance Conference process was explained during this meeting to bring the facility back in compliance. Since licensure in 12/30/20, the facility has been cited 16 times in the last year. The facility was cited for the following issues: Basic services requirements, Incidental Medical and Dental Care, Criminal Record Clearance, Administrator - Qualifications and Duties, Personal Rights of Residents in All Facilities, Additional Personal Rights of Residents in Privately Operated Facilities, Storage Space, AWOL, appraisals and reappraisals. *Issues discussed during the meeting were:* - The amount of complaint's filed and substantiated against this facility since licensure. The facility was cited for 8 Type A citations and 8 Type B citations within the last 12 months. Continued on 809-C

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2022

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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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
	VISIT DATE: 09/30/2022

NARRATIVE

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- Criminal record clearance
- Staff training requirement
- Administrator - Qualifications and Duties
- Personal rights
- Incidental Medical and Dental Care
- Storage space
- Basic services requirements.
- Increase monitoring from Licensing
- Resident AWOL'ed
- Preplacement appraisals
- Reappraisal assessment
- Delay egress is not function correctly
- New LIC 500

The facility has stated they will do the following to achieve continued and substantial compliance:
- New office manager to manage staff association, ensuring staff are associated
- Training on diabetic medication management
- Audit of physical plant, egress doors
- Ensure delay egress is function correctly
- Ensure residents needs are met
- Ensure staff have the tools to meet those needs
- Ensuring disinfecting products are inaccessible to residents.
- Review and update Plan of Operation

The facility shall submit the following to LPA Truong by 10/14/22: Training on criminal record clearance, Guardian Training, Medication Training, LIC 500 and an updated Plan of Operation.

Continued on 809-C

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2022

LIC809 (FAS) - (06/04)

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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
	VISIT DATE: 09/30/2022

NARRATIVE

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It was agreed that the Department will conduct increased visits and will re-evaluate compliance with the facility in approximately 12 months. Technical Support Program was provided to the facility.

Completing the Non-Compliance Conference does not deprive the Department of its authority to take appropriate formal legal action under the Health and Safety Code if such action is deemed necessary by the Regional Manager.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited during this visit. An exit interview was conducted and a copy of this report was provided via email and an electronic email read receipt confirms receiving these documents.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2022

LIC809 (FAS) - (06/04)

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