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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701135
Report Date: 05/25/2023
Date Signed: 05/25/2023 04:25:29 PM


Document Has Been Signed on 05/25/2023 04:25 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:LAGUNA VILLAGE RCFEFACILITY NUMBER:
342701135
ADMINISTRATOR:TECSON, JEROMEFACILITY TYPE:
740
ADDRESS:4524 BIRDSEYE WAYTELEPHONE:
(916) 421-9369
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY:6CENSUS: 6DATE:
05/25/2023
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Jerome Tecson TIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Tung Truong arrived unannounced to conduct a post-licensing inspection on 5/25/23. LPA met with Administrator Jerome Tecson and explained the purpose of the visit. The Administrator certificate expires 5/3/2024 for Jerome Tecson. The facility is licensed for 6 non-ambulatory residents. Hospice waiver approved for 6. There are 6 residents in care at this time of which 2 is on hospice.

LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents in care. LPA observed rooms to have required furniture. LPA observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days which shall be maintained on the premises. The temperature inside the facility was observed to be at 73*F which is within the required range of 68-85*F. The hot water temperature was measured at 118.9*F which is within the required range of 105-120*F.

LPA observed the centrally stored medications area to be locked and inaccessible to residents. LPA observed the fire extinguisher(s) and first aid kits were up to date. LPA observed smoke and carbon monoxide detector(s) in the facility were in good repair.

LPA requested resident and staff files for review. LPA reviewed (6) resident files and (3) staff files, including criminal record clearances. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility. LPA verified staff training for staff file reviews.

Per California Code of Regulations, Title 22 there were no deficiencies cited during today's inspection. Exit interview held, copy of report given.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:
DATE: 05/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/25/2023
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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