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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700886
Report Date: 05/03/2023
Date Signed: 05/03/2023 11:47:53 AM


Document Has Been Signed on 05/03/2023 11:47 AM - 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: 33DATE:
05/03/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Guadalupe RamirezTIME COMPLETED:
10:30 AM
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On 5/3/23, Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced to conduct a quarterly health and safety visit. LPA met with Administrator Guadalupe Ramirez and explained the purpose of the visit.

LPA toured and inspected the physical plant inside and outside to ensure there were no health and safety concerns. The lounge area, lobby, resident rooms, common areas, dining area, and activity room was toured.

LPA observed the facility is clean and in sanitary condition. The hot water measured at 116.4 degrees Fahrenheit which is within the required range of 105-120*F. The temperature inside was observed at 70 degrees Fahrenheit which is within the required range of 68-85*F. Fire extinguishers were up to date. LPA reviewed 3 staff files to ensure staff training and first-aid certification is up to date.

Based on a review of this facility during today’s visit, it was determined that this facility was found to be in compliance at this time.

No deficiencies were observed pursuant to Title 22 rules and regulations, Health and Safety Codes.

Exit interview conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2023
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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