342700886-7-5-2022-27-AS-KHOS-CG2QJ4-20220705121204

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700886
Report Date: 03/24/2022
Date Signed: 07/05/2022 11:10:19 AM

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
03/23/2022 and conducted by Evaluator Avelina Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20220323143616

FACILITY NAME:	GARDENS AT LAGUNA SPRINGS MEMORY CARE, THE		FACILITY NUMBER:	342700886
ADMINISTRATOR:	IRENE CHARNELL		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:	03/24/2022
		UNANNOUNCED	TIME BEGAN:	03:55 PM
MET WITH:	Jennifer Valcazar		TIME COMPLETED:	07:11 PM

ALLEGATION(S):

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Unlawful eviction.
Staff do not have the required training.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced on 03/24/2022 at 1:30 pm to open a complaint, LPA Martinez met with Jennifer Valcazar and explained the purpose of the visit.

Throughout the course of the investigation, LPA conducted interviews and reviewed facility files. It was learned resident 1 (R1) received an eviction letter due to R1's responsible party's weekly menu request and demands. R1 has not violated any of the following: Non-payment of the monthly rate, failure to comply with state or local laws, failure to comply with the general policies of the community. Additionally, the eviction letter that was provided to LPA Martinez did not contain the following:
A copy of the resident’s current service plan.
The relocation evaluation.
A list of referral agencies
As a result, this eviction is unlawful. Deficiency can be found on the 9099-D.
Continued...

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 03/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20220323143616

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: 03/24/2022

NARRATIVE

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Moreover, LPA Martinez reviewed four employee files. Employee one (E1) had supporting new hire training documentation. However, Employee 3 (E3) new hire required Dementia training was not done in a timely manner. Employee 2 (E2) and Employee 4 (E4) files did not contain supporting new hire training documentation. As a result, the facility is not in compliance with Dementia training requirements.

As a result of this investigation, the Department finds these allegations to be Substantiated. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations.

Exit interview was conducted, and a copy of the 9099 report, LIC 9099-D, and appeal rights were given to the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 03/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 27-AS-20220323143616

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: 03/24/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/14/2022 Section Cited CCR 87707(a)(1)	1 2 3 4 5 6 7	87707(a)(1)Training Requirements If Advertising Dementia Special Care, Programming And/Or Environments: residents with dementia or related disorders shall ensure that all direct care staff, described in Section 87706(a)(1), who provide care to residents with dementia, meet the following training requirements:...	1 2 3 4 5 6 7	Facility Staff agrees to complete an employee training audit by POC date 04/14/2022.Facility staff agrees to implement dementia training for all care staff by 04/14/2022. LPA will return to the facility to clear POC.
	8 9 10 11 12 13 14	Direct care staff shall complete six hours of orientation specific to the care of residents with dementia within the first four weeks of working in the facility. This requirement was not met as evidenced by: based on file review 3 employees did not have supporting dementia training documents. This posed a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
Type B 04/14/2022 Section Cited CCR 87224(a)	1 2 3 4 5 6 7	87224(a) Eviction Proceduresthe licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required...This requirment was not met as evidenced by: Based on record review and interviews, R1 was evicted due to Responsible Party's conduct and requests	1 2 3 4 5 6 7	Facility staff agrees to review eviction regulations by POC date 04/14/2022. Facility staff agrees to provide a written statment to LPA that states the review of eviction regulations has been completed by POC Date 04/14/2022.
	8 9 10 11 12 13 14	In addition, eviction letter did not have all the required information. Also, R1 did not violate title 22 eviction reasons. This posed a potential health and safety risk to R1	8 9 10 11 12 13 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-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 03/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2022

LIC9099 (FAS) - (06/04)

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