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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001416
Report Date: 08/28/2023
Date Signed: 08/28/2023 12:04:19 PM

Document Has Been Signed on 08/28/2023 12:04 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 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:
08/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:44 AM
MET WITH:Josephine ShobnaTIME COMPLETED:
12:15 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 conduct an annual required inspection. LPA met with facility staff/Program Manager Josephine Shobhna and explained the purpose of the visit.

LPA observed 4 staff on shift and 3 residents in the home. According to staff, the other residents are at their Day program. LPA observed staff cleaning, assisting residents, completing paperwork, and cooking lunch. Residents were observed doing arts and craft, walking around the house, and watching television. LPA toured the facility with Manager Josephine. Resident bedrooms were fully furnished, clean, and organized. Residents bathrooms were observed to be fully stocked with paper towels, soap, toilet paper, and trash cans. Common areas had required furniture with no emergency exits obstructed. Staff bedrooms were observed to be within compliance. LPA observed an emergency supply of food, water, and linens. The facility had a 30 day supply of PPE. Facility has nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. Hot water in the bathroom was measured at 105.8*degrees F. The room temperature thermostat had a reading of 78*degrees F. LPA observed the backyard to have a sitting area for visits/outdoor activities, a garden area, a locked shed for miscellaneous items, a basketball hoop, and refrigerators for staff/residents. LPA observed a pull alarm system and a fire extinguisher, which was fully charge with a last inspection on 05/19/2023. Medications, sharps, and cleaning supplies were locked away and inaccessible to residents in care.

LPA reviewed 6 resident files and 3 staff files. Files were observed to be up to date. LPA spoke to residents and staff during the visit.

Per California Code of Regulations - Title 22, Division 6, no deficiencies were observed during this visit. An exit interview was held with House Manager Josephine, and a copy of the report was provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 08/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2023
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