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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003430
Report Date: 08/03/2023
Date Signed: 08/03/2023 01:45:26 PM


Document Has Been Signed on 08/03/2023 01:45 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 AC/SC, 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: 2DATE:
08/03/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Leonora CosmeTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit in order to follow up on an incident report. LPA Moleski spoke with administrator Romaine Felix over the phone and explained the purpose of the visit.

LPA Moleski received an illegible incident report on July 13, 2023. Felix said she had scanned and sent the incident report to LPA Moleski. LPA Moleski did not receive a scan of this incident report. LPA Moleski reviewed a copy of this incident report during this visit. The report described a resident (R1) being sent to the hospital for pneumonia and a urinary tract infection on July 9, 2023. LPA Moleski reviewed R1's file.

No deficiencies were cited during this visit. Felix said staff member Leonora Cosme could sign this report in her absence. An exit interview was held and a copy of this report was left with Cosme.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2023
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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