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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700886
Report Date: 09/07/2023
Date Signed: 09/07/2023 05:20:56 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/19/2022 and conducted by Evaluator Tung Truong
COMPLAINT CONTROL NUMBER: 27-AS-20220919221525
FACILITY NAME:GARDENS AT LAGUNA SPRINGS MEMORY CARE, THEFACILITY NUMBER:
342700886
ADMINISTRATOR:STEPHEN SARINEFACILITY TYPE:
740
ADDRESS:9750 LAGUNA SPRINGS DRIVETELEPHONE:
(916) 667-3167
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY:70CENSUS: 34DATE:
09/07/2023
UNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Steve SarineTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Staff physically assaulted resident in care resulting in injuries.
INVESTIGATION FINDINGS:
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On 9/7/23, Licensing Program Analyst (LPA) Tung Truong conducted an unannounced visit to this facility to deliver the complaint findings. LPA met with facility representative Steve Sarine and explained the purpose of the visit.

Throughout the course of the investigation, the Department conducted interviews and reviewed records. Regarding the allegation that staff physically assaulted resident in care resulting in injuries, it was determined that there is insufficient evidence to support the allegation. Based on interviews and records review, resident R1 has had several witnessed falls on 9/16/22 and 9/17/22 and was observed to have sustained bruising on face, chest and swelling in both arms. On 9/18/22, Garden’s staff (S2) witnessed R1 falling face down. Moreover, when the outside agency caregiver (S1) was interviewed, they denied causing any injuries to R1.

Continued on 9099-C
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 27-AS-20220919221525
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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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This Department has investigated the allegations noted above and have found the complaint to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview was conducted and a copy of this report was provided.
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
LIC9099 (FAS) - (06/04)
Page: 2 of 2