342700886-12-13-2021-27-AS-TTRG-C9NRNB-20211213121005

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700886
Report Date: 12/13/2021
Date Signed: 12/13/2021 12:10:11 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, THE		FACILITY NUMBER:	342700886
ADMINISTRATOR:	RICKY DAVID JR.		FACILITY TYPE:	740
ADDRESS:	9750 LAGUNA SPRINGS DRIVE		TELEPHONE:	(916) 667-3167
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95757
CAPACITY:	70	CENSUS: 19	DATE:	12/13/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Lisa Poole-Johnson		TIME COMPLETED:	12:15 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	On 12/13/2021 at 8:45 am, Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced to conduct an annual inspection visit. Prior to entering the facility, LPA Truong called the facility and spoke to staff, who confirmed no residents or staff have had any symptoms of COVID-19 in the last 10 days. Upon LPAs arrival, staff Serena Marquez was present at the front desk and contacted Administrator Lisa Poole-Johnson who arrived a bit later. LPA met with Administrator Lisa Poole-Johnson explained the purpose of today’s visit. Administrator holds current certification #6033977740 and expires on 2/2/2023. The facility is licensed to serve seventy (70) non-ambulatory residents. Hospice waiver approved for 15. There are currently nineteen (19) residents who reside at this facility. LPA toured the facility with Lisa Poole-Johnson on 12/13/2021 at 9:40 am. LPA inspected the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms; resident bathrooms, laundry rooms, medication room and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA observed the facility is clean and in good repair. LPA observed sufficient furniture and lighting throughout the facility. LPA observed bedrooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition and properly maintained. Hot water measured in the kitchen, restroom and resident’s room were within the required range of 105-120 degrees Fahrenheit. LPA observed there to be a sufficient amount of perishable and non-perishable food supply on hand. Medications, toxins, and knives were inaccessible to residents. Report 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: 12/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2021

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: 12/13/2021

NARRATIVE

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Smoke detectors are present in every room and throughout the facility. Facility also has carbon monoxide detectors. Fire extinguishers and first aid kit were up to date. LPA also conducted the infection control domain tool.

The facility mitigation plan was submitted to CCLD, and it was approved on 6/17/2021. Facility has digital sign-in/screening system for residents, staff, and visitors. Hand Hygiene procedures have been implemented. Facility had Covid-19 posters throughout the facility, and the facility has implemented Covid-19 mitigation plan.

Administrator was informed to send updated copies of the following documents to CCL within 15 days:

(1) LIC308 Designation of Administrative Responsibility
(2) LIC500 Personnel Report
(3) Copy of Administrator Certificate
(4) LIC610 Emergency Disaster Plan
(5) Proof of Current Liability Insurance
(6) LIC309 Administrative Organization

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were cited during this visit. An exit interview was held and a copy of this report was provided.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 12/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2021

LIC809 (FAS) - (06/04)

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