<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701137
Report Date: 02/12/2024
Date Signed: 02/12/2024 04:05:16 PM


Document Has Been Signed on 02/12/2024 04:05 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:LAGUNA WOODSFACILITY NUMBER:
342701137
ADMINISTRATOR:KANG, MARIAFACILITY TYPE:
740
ADDRESS:10035 PIANELLA WAYTELEPHONE:
(916) 833-1493
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY:6CENSUS: 5DATE:
02/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Jennylind DuranTIME COMPLETED:
04:20 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to the facility to conduct an annual required inspection. LPA met with facility staff Rose, and explained the purpose of the visit. LPA contacted facility designated staff Jennylind Duran via cell phone to notify of the visit. Staff Jennylind later met with LPA Valerio.

LPA Valerio and facility staff Bonifacio toured the facility to ensure compliance with Title 22 regulations. LPA observed 6 bedrooms, 5 of which were occupied. All bedrooms were furnished with a bed, night stand, lamp, dresser, and a chair. Resident restrooms were observed to be clean, organized, and free from odors. The bathroom water delivered hot water between the regulatory range of 105.0*F - 120.0*F. Restrooms were fully stocked with toilet paper, wipes, hand sanitizer, hand soap, grab bars, and a trash can. Common areas were observed to be clean with no obstructions to walk ways. LPA observed staff cleaning the bathroom, cleaning the kitchen, and assisting residents. Residents were in the kitchen eating lunch, watching television, in their room, or out on an outing. The facility was observed to have medications locked and inaccessible to residents in care. LPA observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises. The first aid kit was fully stocked. Fire extinguishers, Smoke detectors, and carbon monoxide detectors were observed to be within compliance with fire safety.

LPA Valerio observed three (3) resident files and three (3) personnel files. All files were observed to be up to date. Staff had required training. LPA requested the following documentation to be sent to LPA Valerio via fax or e-mail: LIC 500, LIC 308, LIC 610D, Liability Insurance, and copy of Administrator Certificate

Per California Code of Regulation (CCR) - Title 22, Division 6, Chapter 8, no deficiencies were observed during today's visit. An exit interview was held, and a copy of the report was provided.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 02/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1