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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003430
Report Date: 12/30/2021
Date Signed: 02/11/2022 12:52:28 PM

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 STAR HOMEFACILITY NUMBER:
347003430
ADMINISTRATOR:ANGELES, JUNEFACILITY TYPE:
740
ADDRESS:8720 LAGUNA STAR DRIVETELEPHONE:
(916) 684-8787
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY:6CENSUS: 6DATE:
12/30/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator Romaine FelixTIME COMPLETED:
03:30 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
On 12-30-21 LPA Hubbard conducted a unannounced Case management visit. LPA met with facility Administrator Romaine Felix to discuss the purpose of the visit. LPA Hubbard asked if any residents or staff were positive. Administrative stated that there is one presumptive positive who will be retesting. Administrator has notified CCL via Fax and email.

LPA toured the physical plant of the facility and reviewed MAR for all persons in care. The MAR for all 6 residents is up to date and in compliance with CCL regulations. LPA observed staff and residents wearing mask and social distancing.

On 12-9-2021 Alta Regional center conducted a case management visit placing the facility on Sanctions due to medication errors. The regional found substantial inadequacies which pose a danger to residents health and safety or conditions related to consumer services as defined in Title 17, 56054.

On 12-1-2021, ACRC Liaison Support Coordinator (LSC) Jazmin Kung Gunion was present a the Laguna Star Home to conduct an IP meeting. Care Home representative were Assistant Administrator Romaine Felix and staff Anita Gerobin. Medications were reviewed for client UCI# 5525167 and 6320345. The following deficiencies were identified.

Client UCI#5525167 was prescribed Docusate sodium 100mg, 1 to 2 caps daily at bed time as needed. The resident received the medication at 7am and not bedtime.
Client UCI# 6320345- A bottle of Ibuprofen 800 mg was not entered on the centrally Stored medication log.

Deficiencies were corrected and Sanction has been lifted from facility on 12-9-21. No deficiencies were observed during visit.
This report has been amended to remove confidential identifying information.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 559-365-5294
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2022
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