347003430-8-13-2021-27-AS-THUD-C5V4E2-20210813190137

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347003430
Report Date: 08/13/2021
Date Signed: 08/13/2021 07:01:51 PM

Document Has Been Signed on 08/13/2021 07:01 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 STAR HOME		FACILITY NUMBER:	347003430
ADMINISTRATOR:	ANGELES, JUNE		FACILITY TYPE:	740
ADDRESS:	8720 LAGUNA STAR DRIVE		TELEPHONE:	(916) 684-8787
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95758
CAPACITY:	6	CENSUS: 6	DATE:	08/13/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Romain Felix		TIME COMPLETED:	07:00 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) Tirzah Hubbard arrived unannounced to conduct a Required – 1 Year inspection on 8/13/21 at 2:00pm. LPA met with Assistant Administrator Romain Felix, and stated the purpose of today’s visit. LPA were allowed entry into the facility that is licensed to serve a total capacity of 6 clients. LPA interacted with a random number of residents during this visit. The physical plant was tour inside and outside to ensure the safety of the residents. All required furniture were observed. LPA observed residents engaging in activity, wearing a mask and practicing social distancing. LPA observed the facility conducts fire drills monthly. Clients positive for COVID:5 Negative clients: 1 Staff Positive: 1 All required COVID measures were not observed. The Assistant Administrator did not take LPAs temperature or screen for COVID at the door. LPA observed both care givers in the facility not wearing the proper PPE for positive residents. LPA observed 1 positive resident in the entry way of the facility. LPA observed signs and postage. LPA observed outside fencing in good condition. LPA observed in the garage in need of cleaning and trash to be thrown away. The thermostat 74F temperature inside the facility hallway was measured at 71 F which is within the required range of 68 degrees F (20 degrees C) and 85 degrees F (30 degrees C), or in areas of extreme heat the maximum shall be 30 degrees F (16.6 degrees C) less than the outside temperature. The hot water was measured at 113 *F which is not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C) as per Title 22 regulations. LPA observed the centrally stored medications area to be locked and inaccessible to clients. LPA observed 3 of 3 medications counted properly labeled and stored, matching medication administration records (MAR).The first aid kit was found in compliance containing at least the following: a current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency, sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, and Antiseptic solution. LPA observed a pull alarm system, fire extinguisher(s), smoke and carbon monoxide detectors, central heating and air in the facility.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Tirzah Hubbard	TELEPHONE: 559-365-5294
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2021

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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: LAGUNA STAR HOME	FACILITY NUMBER: 347003430
	VISIT DATE: 08/13/2021

NARRATIVE

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LPA observed there were food supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days which shall be maintained on the premises at all times.

Mitigation Plan was submitted and approved.

Upon a file review the following items were discussed to be submitted with any changes annually:
Licensing fees
Criminal Record Clearances LIC536
Administrative Organization LIC309
Designation of Administrative Responsibility LIC308
Personnel Report LIC500
Qualifications of Administrator/Facility Manager- Administrator certificate
Emergency Disaster Plan LIC610D
In-service Training Program
First aid/CPR certificates

LPA trained administrator Romain Felix and caregiver Anita Gerobin to discuss and go over Donning and Doffing procedures. LPA implemented on how to put gown, shield, shoe covers, and gloves on and how to take the off. LPA requested both S1 and S2 to keep the PPE on for the remainder of the visit.

LPA discussed the procedures of the quarantine and isolation and the importance of following Covid 19 procedures. LPA discussed the

TV:
Garage contains old mattresses Administrator has agreed to remove items out of garage by 8-18-21.
LPA observed trash in the back yard with scheduled time for pick up by administrator.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, there were deficiencies cited during this visit on 809D. Exit interview held and a copy of report was given.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Tirzah Hubbard	TELEPHONE: 559-365-5294
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2021

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 07/26/2022 03:25 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 08/14/2021 02:26 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 HOME	FACILITY NUMBER: 347003430
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/13/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Personnel Requirements - General


	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date:
	Plan of Correction
1 2 3 4

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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 Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Tirzah Hubbard	TELEPHONE: 559-365-5294
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2021

LIC809 (FAS) - (06/04)

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