342700886-12-15-2023-27-AS-RWAE-CYHSH4-20231214125256

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700886
Report Date: 12/14/2023
Date Signed: 12/15/2023 02:48:51 PM

Document Has Been Signed on 12/15/2023 02:48 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, THE		FACILITY NUMBER:	342700886
ADMINISTRATOR:	RAMIREZ, GUADALUPE		FACILITY TYPE:	740
ADDRESS:	9750 LAGUNA SPRINGS DRIVE		TELEPHONE:	(916) 667-3167
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95757
CAPACITY:	70	CENSUS: 30	DATE:	12/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Guadalupe Ramirez - Administrator		TIME COMPLETED:	01:15 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	Licensing Program Analyst (LPA) Ruth Wallace conducted an unannounced 1 Year Annual Inspection Visit. LPA met with Administrator and explained the purpose of the visit. Administrator assisted with today’s visit. The facility had a mitigation plan completed and approved on 6/17/2021. LPA toured and inspected the physical plant inside and outside with administrator to ensure there were no health and safety concerns. LPA observed the lounge area, lobby, and common areas. In addition, the kitchen areas, dining area, and activity room was toured. A review was conducted of the apartment sizes and different layouts. Each unit has mini-split air and heating unit. The medication room was toured. Kitchen pantry and walk-in freezer was toured for adequate food supplies and storage. LPA observed required furniture and lighting throughout the facility. The hot water temperature was measured at 113.4F in resident apartment during this visit. Facility shall maintain the hot water temperature within the required range of 105-120F. The temperature inside the facility measured at 73F which was within the required range of 68-85F. LPA observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises. LPA observed the centrally stored medication areas to be locked and made inaccessible to the residents at this time. LPA observed the fire extinguisher(s) were last inspected on December 7, 2023. First aid kits were up to date. Smoke and carbon monoxide detector(s) in the facility were in good repair. Continued on 809-C Page 2

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth Wallace	TELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

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: 12/14/2023

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Continued from 809 - Page 2

LPA reviewed seven resident files and seven staff files, including criminal record clearances. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks are Fingerprint cleared and associated to the facility. LPA verified staff training for staff file reviews.

LPA requested the following documents for facility file to be sent via email by December 20, 2023: LIC 308 Designation of Facility Responsibility, LIC 500 Personnel Report, LIC 610-E Emergency Disaster Plan, and Liability Insurance.
ruth.wallace@dss.ca.gov

Per the California Code of Regulations, Title 22, Division 6, Chapter 6, no violations cited during this visit.
Exit interview held with administrator.

A copy of report and LIC 811 (Confidential Names) left at facility.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth Wallace	TELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

LIC809 (FAS) - (06/04)

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