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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001416
Report Date: 10/11/2022
Date Signed: 10/11/2022 11:29:54 AM

Document Has Been Signed on 10/11/2022 11:29 AM - 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 STREAM FAMILY HOME,INC.FACILITY NUMBER:
347001416
ADMINISTRATOR:SALVADOR, RYANFACILITY TYPE:
735
ADDRESS:8921 SHADY VISTA COURTTELEPHONE:
(916) 685-5618
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 6DATE:
10/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Ryan SalvadorTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Christina Valerio arrived to the facility unannounced to conduct an annual inspection. LPA Valerio met with facility staff, and stated the purpose of today’s visit. Licensee arrived at the facility shortly after LPA.
 
The physical plant was toured inside and outside to ensure the safety of the residents and compliance with Title 22 regulations. The infection control tool was completed during the visit. Facility staff were observed to be wearing required PPE and were aware of current policies regarding infection control.
 
LPA and licensee observed the temperature inside the facility was measured at 72*F, which is within the required range of 68 degrees F and 85 degrees F. The hot water was measured at 105.3 *F. Facility has nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. LPA observed the centrally stored medications area to be locked and inaccessible to clients. LPA Valerio observed the pull alarm, fire extinguisher(s), smoke and carbon monoxide detectors, central heating, and air in the facility. Fire Extinguisher last check on 05/25/2022. A first aid kit and an emergency supply of food and water was observed. No obstructions to emergency exits were observed.
 
LPA Valerio requested the following documentation be sent: LIC 500, Administrator Certificate, LIC 610E, Infection Control Plan, Infection Control Plan - Monkey Pox, Surety Bond

Per the California Code of Regulations, Title 22, no deficiencies were observed or cited.  Exit interview held, and a report was left at the facility.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 10/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/11/2022
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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