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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700886
Report Date: 04/07/2022
Date Signed: 04/07/2022 04:11:06 PM

Substantiated


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
01/03/2022 and conducted by Evaluator Tung Truong
COMPLAINT CONTROL NUMBER: 27-AS-20220103142529
FACILITY NAME:GARDENS AT LAGUNA SPRINGS MEMORY CARE, THEFACILITY NUMBER:
342700886
ADMINISTRATOR:LISA POOLE-JOHNSONFACILITY TYPE:
740
ADDRESS:9750 LAGUNA SPRINGS DRIVETELEPHONE:
(916) 667-3167
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY:70CENSUS: 29DATE:
04/07/2022
UNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Mary Keaton, AdministratorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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5
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7
8
9
Resident's room has a water leak
Staff did not safeguard residents personal belongings
Staff are not providing adequate laundry service
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analysts (LPAs) Tung Truong and Avelina Martinez arrived at this facility unannounced on 04/07/2022 at 10:20 am to conclude the investigation of the above allegations and to deliver the findings. LPAs met with Administrator Mary Keaton and explained the purpose of the visit.

Throughout the course of the investigation, LPA Truong conducted interviews, reviewed facility documents, and toured the facility.

Throughout the investigation, it was learned resident 1's (R1) AC unit was not in good repair. The AC unit was retaining rain water causing R1's room carpet floor to have excess water. It was also observed that towels were placed under the AC unit to soak up the excess water. As a result, the facility did not ensure R1's room was sanitary and ensure that R1's AC unit was in good repair at all times.

Report continued on 9099-C
Substantiated
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: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022
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 6
Control Number 27-AS-20220103142529
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: 04/07/2022
NARRATIVE
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Moreover, 5 out of 7 interviewees reported residents' clothing have been lost or misplaced due to staff not returning clothes to the correct resident after being washed by facility staff. The facility did not safeguard residents' clothing, and did not provide adequate laundry service.

As a result of this investigation, the Department finds the allegations above to be SUBSTANTIATED. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations.

An exit interview was conducted with Mary Keaton, a copy of this report, LIC 9099-D, and appeal rights were provided.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 6
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
01/03/2022 and conducted by Evaluator Tung Truong
COMPLAINT CONTROL NUMBER: 27-AS-20220103142529

FACILITY NAME:GARDENS AT LAGUNA SPRINGS MEMORY CARE, THEFACILITY NUMBER:
342700886
ADMINISTRATOR:LISA POOLE-JOHNSONFACILITY TYPE:
740
ADDRESS:9750 LAGUNA SPRINGS DRIVETELEPHONE:
(916) 667-3167
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY:70CENSUS: 29DATE:
04/07/2022
UNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Mary Keaton, AdministratorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not prevent resident's from engaging in inappropriate behaviors
Resident sustained a rash while in care
Staff did not notify resident's authorized representative of injury
Staff are not properly cleaning resident's room
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analysts (LPAs) Tung Truong and Avelina Martinez arrived at this facility unannounced on 04/07/2022 at 10:20 am to conclude the investigation of the above allegation and to deliver the findings. LPAs met with Administrator Mary Keaton and explained the purpose of the visit.

Throughout the course of the investigation, LPA Truong conducted interviews, reviewed facility documents, and toured the facility.

The complaint alleged that staff did not prevent resident's from engaging in inappropriate behaviors. Based on interviews and statements obtained during the investigation, it was determined that there was insufficient evidence to substantiate that staff did not prevent resident's from engaging in inappropriate behaviors.

Report 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: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 27-AS-20220103142529
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: 04/07/2022
NARRATIVE
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The complaint alleged that a resident sustained a rash while in care. Based on interviews and review of records, it was learned that resident R1 has a rash of unknown cause. It was learned that R1 also going out into the community. As a result, LPA was unable to determine if the rash happened while in care.

The complaint alleged that staff did not notify resident's authorized representative of R1's injuries. Based on interviews and review of records, it was learned that facility staff did notify R1’s responsible party of R1’s rash on 10/21/21 and 11/16/21. Based on interviews and statement obtained, residents and residents’ authorized representatives stated that their communication with the facility have been good and that the facility have been good on notify them of any concerns.

The complaint alleged that staff are not properly cleaning resident's room. Based on interviews and observations, LPA observed a total of 10 residents' rooms on three different visit from 10/06/22 through 3/24/22. All of the rooms observed are clean.

Based on information obtained, the department finds the allegations above 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 with Administrator and a copy of the 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: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 27-AS-20220103142529
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/20/2022
Section Cited
CCR
87303(a)
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Maintence and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times.
This requirement is not met as evidence by:
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5
6
7
Licensee and LPA agree to: Submit letter stating knowledge of, understanding of regulation 87303(a). Correction due 4/14/22. The facility had fixed the PTAC unit in R1's room.
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Based on observation and interviews, the licensee did not maintain the facility in good repair at all times. R1's room had a water leak due to the PTAC unit was not in good repair. This poses a potential health and safety risk to residents in care.
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9
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Type B
04/20/2022
Section Cited
CCR
87468.1(a)(12)
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7
Personal Rights of Residents in All Facilities. To wear their own clothes; to keep and use their own personal possessions.
This requirement is not met as evidence by:
1
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5
6
7
Licensee and LPA agree to: Submit a plan on how the facility will ensure that residents' belongings won't get lost or misplaced.
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Based on observation and interviews, the licensee did not ensure that residents' cloths are properly returned to the right resident. This poses a potential health and safety risk to residents in care.
8
9
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14
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: 04/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 27-AS-20220103142529
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/20/2022
Section Cited
CCR
87307(a)(3)(F)
1
2
3
4
5
6
7
Personal Accommodations & Services. The licensee shall assure provision of basic laundry service…
This requirement is not met as evidence by:
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7
The licensee shall provide LPA Truong with a copy of its laundry service plan of operation, staff sign-in sheet regarding general laundry services
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14
Based on interviews, the licensee did not ensure that residents receive adequate laundry services. This poses a potential health and safety risk to residents in care.
8
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10
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14
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7
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7
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7
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: 04/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6