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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700886
Report Date: 09/07/2023
Date Signed: 09/07/2023 05:26:23 PM


Document Has Been Signed on 09/07/2023 05:26 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: 34DATE:
09/07/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Steve SarineTIME COMPLETED:
05:40 PM
NARRATIVE
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On 9/7/23, Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced to conduct a case management visit. LPA met with facility representative Steve Sarine and explained the purpose of the visit.

The purpose of the case management visit is to follow up on deficiencies found during a complaint investigation conducted by the Department for complaint dated 9/19/2022, control number: 27-AS-20220919221525

The following deficiencies were identified during the complaint investigation:

- Personal Rights - Staff blocked resident (R1’s) doorway with a couch to prevent resident from leaving. This incident was witnessed by facility staff.
- Administrator Qualifications - The designated administrator (A1) did not act in their capacity as the Administrator. A1 told the Department that he was hired as a consultant and was working in the facility only until designated administrator (A2) could obtain their Administrator certificate. On 8/4/22, during a non-compliance meeting, A1 was designated as the facility administrator.
- Basic Services - Facility did not provide adequate supervision which resulted in R1 sustaining multiple injuries from falls. During the investigation, (A1) stated that the private care agency will provide all the care and supervision to the resident, however per Department guidelines, private agencies are only allowed to provide companion services not care and supervision.

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: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2023
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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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: 09/07/2023
NARRATIVE
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- Plan of Operation - Observation of resident change in condition, bruises, prohibited condition. Per facility’s Plan of Operation which stated that a condition of combative, dangerous behavior or the inability to get along in a congregate setting is prohibited and would make the resident inappropriate for admission/move in. During the investigation, it was learned that R1 has displayed aggression towards staff on multiple occasions. Moreover, R1’s Physician’s Report also stated that R1 has behavioral disturbance and aggressive condition.

As a result, deficiencies were cited on LIC 809-D pursuant to the California Code of Regulations, Title 22, and California Health and Safety Code.

An exit interview was conducted, a copy of this report, LIC 809-D and appeal rights were provided. Failure to correct any deficiencies by plan of correction due date(s) may result in civil penalties.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 09/07/2023 05:26 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: 09/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/08/2023
Section Cited
CCR
87468.1(a)(3)

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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse.
This requirement is not met as evidenced by:
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Licensee agrees to submit a plan of correction to LPA by 9/8/23 on how the facility will be in compliance with regulation 87468.1(a)(3) at all times.
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Based on the department's findings, the licensee did not ensure R1 was free from punishment while in the care. Facility staff blocked R1's doorway with a couch to prevent R1 from leaving, which poses an immediate health and safety risk to residents in care.
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Type A
09/08/2023
Section Cited
CCR87405(b)

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87405. Administrator Qualifications and Duties
(b) The administrator of a facility or facilities shall have the responsibility and authority to carry out the policies of the licensee.
This requirement is not met as evidence by:
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Licensee agrees to submit a plan of correction to LPA by 9/8/23 on how the facility will be in compliance with regulation 87405(b) at all times.
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Based on interviews and records review, facility representative A1 denied the fact that he was the responsible administrator. This poses an immediate 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: 09/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 09/07/2023 05:26 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: 09/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/08/2023
Section Cited
CCR
87464(f)(1)

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87464 (f)(1) Basic services care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).
This requirement is not met as evidence by:
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Licensee agrees to submit a plan of correction to LPA by 9/8/23 on how the facility will be in compliance with regulation 87464(f)(1) at all times.
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Based on the department's findings, the facility did not provide adequate care and supervision which resulted in R1 sustaining multiple injuries from falls. This posed an immediate health and safety risk to R1.
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Type A
09/08/2023
Section Cited
CCR87208(a)(3)

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87208 Plan of Operation - (a) Each facility shall have and maintain a current, written definitive plan of operation (3) Statement of admission policies and procedures regarding acceptance of persons for services.
This requirement is not met as evidence by:
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Licensee agrees to submit a plan of correction to LPA by 9/8/23 on how the facility will be in compliance with regulation 87208(a)(3) at all times.
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Based on records review, although the facility has a plan of operation in place the facility failed to follow prohibited conditions outlined in the plan of operation regarding combative, dangerous behavior or the inability to get along in a congregate setting. This poses an immediate 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: 09/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4