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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004610
Report Date: 04/25/2022
Date Signed: 04/25/2022 02:31:13 PM

Document Has Been Signed on 04/25/2022 02:31 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 SPRINGS, RCFEFACILITY NUMBER:
347004610
ADMINISTRATOR:ENERO, EDGARFACILITY TYPE:
740
ADDRESS:7818 WYMARK DR.TELEPHONE:
(916) 812-0944
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 6CENSUS: 6DATE:
04/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Nolie Llarenas - AdministratorTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced 1 Year Required Annual Inspection Visit. LPA met with Administrator and explained purpose of visit. Administrator Certificate #6030700740 Expires . There are currently 6 residents who reside at this facility. This facility has a hospice waiver for 2 residents and currently has 2 residents receiving hospice care.

LPA inspected the interior and the exterior of the facility including the common living spaces, 6 resident bedrooms and 2 bathrooms, kitchen and garage. Bathrooms and bedrooms were clean and in good repair. LPA toured the backyard and all exits are accessible and unlocked. There is a locked storage for medications and toxins. Food supply is adequate for 2-day perishable and 7-day nonperishable. Fire Extinguishers expire 6/3/2022. Smoke detectors were checked and found to be in working order. Hot water temperature measured 126.9 F degrees in residents bathroom with the AD which is in required range of 105 to 120 degrees. LPA observed an adequate amount of linens and found the first aid kit to be complete.

LPA reviewed 6 resident records which were all missing LIC 625 initial Appraisal Needs/Services and 4 staff records. LPA reviewed medications for 4 residents comparing with Centrally Stored Medication Record and physician orders. LPA observed that the facility is dispensing medications as prescribed. A review of staff records indicates that all facility staff has received criminal record clearances and/or are associated to this facility. Staff records reviewed indicated current first aid certificates and training completed.

Per the California Code of Regulations, Title 22, the following deficiencies were observed during this inspection and are on 809-D's. If the deficiencies are not corrected by the noted due date civil penalties may beassessed



Exit Interview conducted with Administrator. LPA left copies of reports with Administrator.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 04/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2022
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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Document Has Been Signed on 04/25/2022 02:31 PM - It Cannot Be Edited


Created By: Ruth Wallace On 04/25/2022 at 11:37 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: LAGUNA SPRINGS, RCFE
FACILITY NUMBER: 347004610

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(3)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above in Hot water registered 124.3 F in kitchen sink and 142.5 F in bathroom next to staff office. LPA checked several times during annual inspection which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/26/2022
Plan of Correction
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Licensee agrees to have maintenance company come to facility and calibrate new water heater correctly within 24 hours. LIcensee will submit copy maintenance performed and calibrated water heater to LPA via email by Plan of Correction Date (POC) 4/26/2022.
ruth.wallace@dss.ca.gov
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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
LICENSING EVALUATOR NAME:Ruth Wallace
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 04/25/2022 02:31 PM - It Cannot Be Edited


Created By: Ruth Wallace On 04/25/2022 at 11:37 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: LAGUNA SPRINGS, RCFE
FACILITY NUMBER: 347004610

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87457(c)
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA record review, the licensee did not comply with the section cited above in all six residents were missing initial appraisal of individual service needs which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/02/2022
Plan of Correction
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Licensee agrees to submit copies of all six resident initial appraisal of individual service needs via e-mail to LPM Stephen Richardson by Plan of Correction (POC) date of 05/02/2022.
stephen.richardson@dss.ca.gov
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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
LICENSING EVALUATOR NAME:Ruth Wallace
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2022


LIC809 (FAS) - (06/04)
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