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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700886
Report Date: 10/26/2023
Date Signed: 10/31/2023 09:48:18 AM


Document Has Been Signed on 10/31/2023 09:48 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: 36DATE:
10/26/2023
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Steve SarineTIME COMPLETED:
02:15 PM
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A Non-Compliance Conference (NCC) was conducted on this day, 10/26/2023, by the Sacramento South Regional Office via Teams meeting. The purpose of this Non-Compliance Conference meeting was to follow up with the facility after an initial NCC was held on 9/30/2022. Present in the meeting was Regional Manager (RM) Stephenie Doub, Licensing Program Manager (LPM) Czarrina Camilon-Lee, LPM Stephen Richardson, Licensing Program Analyst (LPA) Tung Truong, LPA Christina Valerio, facility Regional RCFE Stephen Sarine, VP of Operation Michelle Baker and facility staff Barb Rose and Kayleen August. The Non-Compliance Conference process was explained during this meeting to include the Administrative Process as well.

Since the last meeting on 9/30/2022, six new complaints have been filed against the facility and four Type A deficiencies have been cited. The facility was cited for the following issues: Personal Rights of Residents in All Facilities, Administrator Qualifications and Duties, Basic services care and supervision and Plan of Operation.

The focus of the concerns at this time were as followed:

- Designated Facility Administrator-Qualifications/Duties
- Maintaining continued compliance
- Oversight of facility staff for proper care and supervision
- Facility staff roles, duties, and responsibilities
- Plan of Operation regarding outside agency

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: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2023
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: 10/26/2023
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- Plan of Operation regarding resident with behaviors
- Adhering to the Plan of Operation
- Outside staff fingerprint clearance and facility association

Licensee agreed to do the following in order to bring the facility into compliance: Please provide the following to LPA by 11/3/23.

- Provide updated Plan of Operation regarding admitting resident with behaviors
- Provide updated policies and procedures regarding using outside agency staff
- All staff including administrator shall receive training on Resident Intervention and Redirecting
- All staff and administrator shall receive in-service training on Reporting Requirements

Exit Interview

Licensee/Administrator signature on file.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023
LIC809 (FAS) - (06/04)
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