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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001416
Report Date: 09/06/2024
Date Signed: 09/06/2024 12:13:09 PM

Document Has Been Signed on 09/06/2024 12:13 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 STREAM FAMILY HOME, INC.FACILITY NUMBER:
347001416
ADMINISTRATOR/
DIRECTOR:		SALVADOR, RYANFACILITY TYPE:
735
ADDRESS:8921 SHADY VISTA COURTTELEPHONE:
(916) 685-5618
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 6DATE:
09/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:04 AM
MET WITH:Josephine Shobhna, Facility ManagerTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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On 9/6/24, at 10:04am, Licensing Program Analyst (LPA) Arvin Villanueva arrived unannounced at this facility to conduct their required annual inspection visit. LPA met with Josephine Shobhna, Facility Manager (FM) and explained the purpose of the visit. During this visit, 6 clients in care were out in the community. Facility is currently providing service to 6 ambulatory adult clients.

At 10:15 a.m., LPA and FM conducted a thorough inspection of the facility’s physical plant. Situated in a residential neighborhood, the facility is a well-maintained one-story home. Both the front and back yards were noted for their cleanliness and free of obstructions. A designated outdoor area, furnished for client use, is provided at the back of the property. The fences and gate are currently in good repair. During the inspection, Technical Assistance (TA) was offered to FM to address an issue with the gate’s string, ensuring it remains untangled for smooth operation and anyone can unlock it without difficulties.

Three client bedrooms were inspected and observed to be clean and large enough space to accommodate client belongings. Bedrooms are shared/double occupancy. Three bathrooms were inspected and observed to be clean and in good repair. LPA observed the trash bins in bathrooms do not have lids. Technical assistance was provided for licensee to obtain trash bins with lids on. The kitchen was inspected and observed to be sanitized and in good repair. Food supplies were stored properly. Facility maintains an adequate amount of food supply with 2-day perishables and 7-day nonperishables. Smoke detectors were observed in each bedrooms and hallways. Facility has at least one carbon monoxide monitor. One smoke detector and the carbon monoxide detector in the hallway were tested and found to be operable during this visit. Sharps, toxins and medications were observed to be locked and inaccessible to clients. Facility was observed to have adequate supply of linens for clients. Fire extinguisher was observed and last serviced on 5/14/24. Room temperature was at 78*F and hot water temperature was at 110*F in hallway bathroom. Fireplace was observed to be screened and not accessible to clients.
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SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE: DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/06/2024
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: LAGUNA STREAM FAMILY HOME, INC.
FACILITY NUMBER: 347001416
VISIT DATE: 09/06/2024
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LPA reviewed 3 of 6 client records and found to be in compliance at this time. LPA review and counted with FM 3 of 6 clients' P&I money and found to be accurate. LPA reviewed 2 of 6 clients medications. LPA reviewed 3 personnel records and records were found to be in compliance at this time with current 1st Aid/CPR certificates and background clearance. All 3 staff reviewed have DSP 1 and 2 certificates. Facility conducts monthly emergency drills with last drill was conducted on 9/5/24. LPA also reviewed facility's emergency procedures and infection control plan. TA was provided to licensee to ensure their infection control plan is reviewed at least annually and to add contact information of emergency personnel. TA was also provided to licensee to include at least 2 relocation shelters in their emergency procedure plan.

LPA requested copies of the following documents to be emailed: current Liability Insurance Certificate, Surety Bond, LIC500, and LIC308.

Based on today's inspection, per the California Code of Regulations, Title 22, Division 6, Chapter 6, deficiencies were observed or cited.
Exit interview held with Josephine Shobhna, and a copy of this report was provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024
LIC809 (FAS) - (06/04)
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