<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700886
Report Date: 12/15/2022
Date Signed: 12/15/2022 12:31:52 PM


Document Has Been Signed on 12/15/2022 12:31 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:RAMIREZ, GUADALUPEFACILITY TYPE:
740
ADDRESS:9750 LAGUNA SPRINGS DRIVETELEPHONE:
(916) 667-3167
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY:70CENSUS: 32DATE:
12/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Guadalupe RamirezTIME COMPLETED:
12:45 PM
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
Licensing Program Analysts (LPAs) Tung Truong and Pang Lee conducted an unannounced 1 Year Annual Inspection Visit on 12/15/22. LPAs met with Administrator Guadalupe Ramirez and explained the purpose of the visit. Administrator assisted with today’s visit. Administrator Certificate # 6035691740, expiration date:7/12/2023.

The facility had COVID -19 posters and signs throughout the facility. The facility had a mitigation plan completed and approved on 6/17/2021. The facility had one central entry point, and the facility had routine symptom screening checks for residents, staff, and visitors. The facility had a symptom check binder for staff, residents, and care staff. Hand Hygiene procedures have been implemented.

LPAs toured and inspected the physical plant inside and outside with administrator to ensure there were no health and safety concerns. LPAs observed the lounge area, lobby, and common areas. In addition, the kitchen areas, dining area, and activity room was toured.

A review was conducted of the apartment sizes and different layouts. Each unit has mini-split air and heating unit. The medication room was toured. Kitchen pantry and walk-in freezer was toured for adequate food supplies and storage. LPAs observed required furniture and lighting throughout the facility. The hot water temperature was measured at 117*F in resident apartment during this visit. Facility shall maintain the hot water temperature within the required range of 105-120*F. The temperature inside the facility measured at 69*F which was within the required range of 68-85*F.

Continued on 809-C
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


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: 12/15/2022
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
26
27
28
29
30
31
32
LPAs observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises. LPAs observed the centrally stored medication areas to be locked and made inaccessible to the residents at this time. LPAs observed the fire extinguisher(s) and first aid kits were up to date. Smoke and carbon monoxide detector(s) in the facility were in good repair.

LPAs requested resident and staff files for review. LPAs reviewed (5) resident files and (5) staff files, including criminal record clearances. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks are Fingerprint cleared and associated to the facility. LPAs verified staff training for staff file reviews.

Per the California Code of Regulations, Title 22, Division 6, Chapter 6, no violations cited during this visit.
Exit interview held, copy of report given.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2