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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700886
Report Date: 06/23/2022
Date Signed: 06/23/2022 02:46:59 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
05/16/2022 and conducted by Evaluator Tung Truong
COMPLAINT CONTROL NUMBER: 27-AS-20220516090722
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:
06/23/2022
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Mary KeatonTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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9
Facility is not providing resident's medication as prescribed.

INVESTIGATION FINDINGS:
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On 06/23/22 at 1:30 pm, Licensing Program Analyst (LPA) Tung Truong arrived at the facility unannounced to conclude the investigation of the above allegations and to deliver the findings. LPA met with Administrator Mary Keaton and explained the purpose of the visit.

Throughout the course of the investigation, LPA conducted interviews and reviewed records. The complaint alleged the facility is not providing resident's medication as prescribed. Based on the interviews and reviewed of records, it was learned that on 4/29/2022, resident (R1) was given insulin at approximately 10:00am, two hours late by staff (S3). LPA Truong was unable to contact S3 for a statement. According to staff (S1) and (S4), doctor’s order to give insulin at mealtime of 8am, 12pm, and 5pm. Staff (S1, S2 and S4) confirmed that R1 received his insulin two hours late on 4/29/22.

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: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2022
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 4
Control Number 27-AS-20220516090722
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: 06/23/2022
NARRATIVE
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Due to the above noted information, staff S3 did not provide insulin to R1 at the prescribed time by physician’s order.

As a result of this investigation, the Department finds this allegation 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.

Deficiency was cited on the LIC 9099-D of Complaint Control Number 27-AS-20220503081127, per Title 22 Regulations.

An exit interview was conducted, and a copy of the 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: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
05/16/2022 and conducted by Evaluator Tung Truong
COMPLAINT CONTROL NUMBER: 27-AS-20220516090722

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:
06/23/2022
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Mary KeatonTIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff were rude and slammed door infront of family member.
INVESTIGATION FINDINGS:
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On 06/23/22 at 1:30 pm, Licensing Program Analyst (LPA) Tung Truong arrived at the facility unannounced to conclude the investigation of the above allegations and to deliver the findings. LPA met with Administrator Mary Keaton and explained the purpose of the visit.

Throughout the course of the investigation, LPA conducted interviews and reviewed records. The complaint alleged that facility staff were rude and slammed door in front of family member. Based on the interviews, staff (S4) stated he doesn't recall the door was slammed; if it did, it was not intentional. S4 stated neither he nor the family member had raised their voices. There was insufficient evidence to substantiate the allegation above.

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: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20220516090722
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: 06/23/2022
NARRATIVE
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As a result of this investigation, 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.

An exit interview was conducted, and a copy of the 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: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4