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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701138
Report Date: 06/02/2023
Date Signed: 06/02/2023 12:32:47 PM


Document Has Been Signed on 06/02/2023 12:32 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:COMFORTS OF HOME LAGUNA PARKFACILITY NUMBER:
342701138
ADMINISTRATOR:KANG, MARIAFACILITY TYPE:
740
ADDRESS:5721 LAGUNA PARK DRIVETELEPHONE:
(916) 833-1493
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY:6CENSUS: 6DATE:
06/02/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jenny DuranTIME COMPLETED:
12:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct an annual inspection. LPA Moleski spoke with administrator Maria Kang over the phone and explained the purpose of the visit. Kang said she was unavailable but that co-administrator Jenny Duran would be able to sign this report in her absence.

Kang's administrator certificate number is 6020167740 and it expires on 9/2/2024.

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

LPA Moleski reviewed LIS and discovered that S1 had not been associated to this facility. Duran said she had incorrectly associated her to the facility's former number, not the current facility number.

R1's LIC 602 indicated that R1 has dementia. R1's latest LIC 602 form was dated 5/14/21, which is more than one year old.

LPA Moleski toured the facility with Duran and inspected common areas, the kitchen, resident bedrooms, bathrooms, and backyard areas. Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 73 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature was tested and measured 105 degrees Fahrenheit, which is within the required range of 105 and 120 degrees.

[Continued on 809-C]
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: COMFORTS OF HOME LAGUNA PARK
FACILITY NUMBER: 342701138
VISIT DATE: 06/02/2023
NARRATIVE
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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 the required minimum 2-day perishable supply of food and a minimum 7-day supply of nonperishable food. LPA Moleski observed locked cabinets for the storage of medication. LPA Moleski observed a locked closet for the storage of cleaning solutions. LPA Moleski observed a locked cabinet for the storage of knives.

LPA Moleski interviewed two staff members (S1, S3) and two residents (R4, R5).

This facility is being cited per 22 CCR Section 87355(e)(3) and 87705(c)(5). An exit interview was held with Duran. Appeal rights and a copy of this report were left with Duran.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 06/02/2023 12:32 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: COMFORTS OF HOME LAGUNA PARK
FACILITY NUMBER: 342701138

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on review of LIS and based on interview with Duran, the licensee did not transer S1's criminal record clearance to the correct facility, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/03/2023
Plan of Correction
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Licensee agrees to email LPA Moleski proof of requesting criminal background clearance transfer for S1 to the correct facility roster by the POC due date.
vincent.moleski@dss.ca.gov
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 06/02/2023 12:32 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: COMFORTS OF HOME LAGUNA PARK
FACILITY NUMBER: 342701138

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on review of R1's file, the licensee did not acquire an updated LIC 602 for R1 within a year, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2023
Plan of Correction
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Licensee agrees to acquire an updated LIC 602 by the POC due date. Licensee agrees to email LPA Moleski the new 602 form.
vincent.moleski@dss.ca.gov
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4