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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701134
Report Date: 05/23/2023
Date Signed: 05/23/2023 12:55:52 PM


Document Has Been Signed on 05/23/2023 12:55 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
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:LAGUNA SPRINGS RCFEFACILITY NUMBER:
342701134
ADMINISTRATOR:ENERO, EDGARFACILITY TYPE:
740
ADDRESS:7818 WYMARK DRIVETELEPHONE:
(916) 682-4742
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY:6CENSUS: 5DATE:
05/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Jerome TecsonTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct an annual inspection. LPA Moleski met with administrator Jerome Tecson and explained the purpose of the visit.

Tecson's administrator certificate number is 6032076740 and it expires on 8/19/2024.

LPA Moleski reviewed three resident files (R1-R3) and three staff files (S1-S3).

LPA Moleski toured the facility with Tecson and inspected common areas, the kitchen, bedrooms, bathrooms, and backyard areas. Furniture and furnishings were sufficient to meet the needs of residents.

LPA Moleski observed a first aid kit, a fully-charged and up-to-date fire extinguisher, and working carbon monoxide/smoke detectors. LPA Moleski observed a minimum 2-day perishable supply of food and a minimum 7-day supply of nonperishable food. LPA Moleski observed a locked cabinet for the storage of medication. LPA Moleski observed a locked closet for the storage of cleaning solutions. LPA Moleski observed a locked drawer for the storage of knives.

LPA Moleski interviewed two staff members (S1 and S2) and two residents (R1 and R2).

Any observed deficiencies were notated and cited on the preceding post-licensing inspection report. An exit interview was conducted and a copy of this report was left with Tecson.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2023
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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