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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700886
Report Date: 06/13/2022
Date Signed: 06/13/2022 04:20:19 PM


Document Has Been Signed on 06/13/2022 04:20 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:MARY KEATONFACILITY TYPE:
740
ADDRESS:9750 LAGUNA SPRINGS DRIVETELEPHONE:
(916) 667-3167
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY:70CENSUS: 31DATE:
06/13/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Kirk GoodinTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analysts (LPA) Avelina Martinez and LPA Arielle Pascua arrived at facility unannounced to conduct a case management visit on 06/13/2022. LPA Martinez and LPA Arielle Pascua met with Kirk Goodin and explained the purpose of the visit.

The purpose of the visit today, is in response to learned deficiencies during a complaint investigation. Resident 1 (R1) had various significant physical, medical, and mental changes while residing at this facility. The facility staff documented R1's condition changes on daily nurse's notes and via physician fax communication sheet. However, a reassessment after each significant health change was not being completed. LPA Martinez obtained two different forms of R1's health assessments. One assessment was dated January 19, 2022 and the other was date April 10, 2022.

Beginning on February 9, 2022, it was noted R1 was having suicidal ideations and continued on February 12,2022. Moreover, monitoring of R1 occurred on the following dates: February 12, 2022; February 13, 2022; February 17, 2022; February 18, 2022; February 19, 2022; and the last monitoring entry was on February 20, 2022.

Furthermore, facility staff informed R1's physician of the suicidal ideations via fax communication on February 22, 2022 and requested an order for Seroquel. There are no other notes that indicate R1's responsible party was informed of the suicidal ideations. There was no other documentation noting the facility staff continued to monitor R1's suicidal ideations. Additionally, the facility did not complete a new assessment after R1's suicidal ideations incidents.

Continued...

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2022
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: 06/13/2022
NARRATIVE
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It was also, learned R1 had multiple falls, and one fall with a serious injury. R1's January 19, 2022 assessment service plan reported R1 had a history of falling and had a score of one point. R1's first recorded fall was on February 1, 2022. After the initial first fall, R1 fell 6 more times. On March 16, 2022, R1 went out the facility egress doors onto the gated patio and fell. At this fall, R1 broke his nose. R1 was sent to the emergency room for care. The facility did not conduct a reassessment service plan in regards to fall prevention and care needs after the March 16, 2022 fall. It was not until April 10, 2022 that facility conducted a reassessment service plan. The April 10, 2022 reassessment service plan reported two or more falls in the last 30 days (impulsive to shift wt/transfer or ambulate, unsteady gate).This assessment service plan was not signed by R1's responsible party.

On this 809 Licensing Report (LIC 809), this facility was given notice of a violation for which a civil penalty is prescribed by California Health and Safety Code Section 1548(c), 1568.0822(c), 1569.49(c), 1596.99(c), or 1597.58(c). The facility did not conduct reassessments in a timely manner, and did not address R1' eloping tendencies. Due to not addressing R1's eloping/exiting tendencies and fall risk need, R1 engaged in eloping/exit seeking behaviors during mid-night hours and sustained a fall and broke his noes. As a result, an immediate $500.00 civil penalty shall be assessed on June 13, 2022 for bodily injury and severe pain, which posed an immediate threat to the Health, Safety, and Personal Rights of R1.



R1's January 19, 2022 assessment states Cognitive Ability: Mental and emotional," wandering into other residents rooms..." On this assessment R1 was scored a 4. R1 began exhibiting exit seeking and wandering behaviors on January 20, 2022 although R1 was not reassessed. LPA Martinez reviewed January 20, 2022 through March 29, 2022 facility notes, and R1 had exit/elopement seeking behaviors on twenty-six different days during this period. On March 23, 2022, it was noted R1 was exhibiting elopement behaviors and attempted to climb over the counter in the nurse's station. During this time period, it was also noted it was difficult to redirect R1. R1 was also having unusual behaviors, such as, moving furniture around. R1 also developed a stooped gated on March 26, 2022. However, R1 was not reassessed until April 10, 2022, and was scored a seven, which stated, "attempts to wander from community...exit seek throughout the day and night...unsteady gate"

As a result of the gathered information, the facility did not keep R1's reappraisal/assessments updated after each significant health change and did not immediately bring changes to his primary physician and responsible party.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 06/13/2022 04:20 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: 06/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/16/2022
Section Cited

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87468.2(a)(4)Additional Personal Rights of Residents in Privately Operated Facilities: in addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities...To care, supervision, and services that meet their individual needs and are delivered by
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staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is met as evidence by. Based on file reviews R1 did not receive care and supervision conducive to his exit/eloping seeking behaviors which lead to breaking nose, suicidal ideations, unusual behaviors. This posed an immediate health and safety risk to R1.
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Type B
06/08/2022
Section Cited

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87463(a)(3) Reappraisals Any illness, injury, trauma, or change in the health care needs of the resident that results in a circumstance or condition specified in Sections 87455(c) or 87615, Prohibited Health Conditions. This requirement is not met as evidence by:
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Based on file reviews and interviews, reappraisals were not being conducted after R1's significant changes. This posed a potential health and safety risk to R1.
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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: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2022
LIC809 (FAS) - (06/04)
Page: 3 of 5


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: 06/13/2022
NARRATIVE
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During today's visit LPA Martinez and LPA Pascua observed cleaning cart compartments were left unlock. Cleaning cart compartments had cleaning supplies and made accessible to residents in care.

As a result of this Case Management visit, the following deficiencies were observed and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. The deficiencies can be found on the 809-D Page. An exit interview was conducted and appeal rights given.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2022
LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 06/13/2022 04:20 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: 06/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/14/2022
Section Cited

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Storage Space 87309(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement was not met as evidence by:
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Based on observation, cleaning carts compartments were left unlocked, which made cleaning toxins accessible to residents in care. This posed 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: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2022
LIC809 (FAS) - (06/04)
Page: 5 of 5