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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701448
Report Date: 10/15/2024
Date Signed: 10/16/2024 07:39:07 AM

Document Has Been Signed on 10/16/2024 07:39 AM - 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 CARE HOMEFACILITY NUMBER:
392701448
ADMINISTRATOR/
DIRECTOR:		PAYANG, LINDAFACILITY TYPE:
735
ADDRESS:294 LAGUNA DRTELEPHONE:
(209) 834-7598
CITY:TRACYSTATE: CAZIP CODE:
95376
CAPACITY: 5CENSUS: 5DATE:
10/15/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Linda PayangTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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On 10/15/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived announced to this facility to conduct a pre-licensing visit. LPA met with applicant Linda Payang and explained the purpose of the visit.
The purpose of this visit was to conduct a pre-licensing visit.

This facility has a fire clearance for 5 residents, of which 3 may be non-ambulatory and 2 may be bedridden in rooms 1 and 3. This facility is also awaiting vendorization from Valley Mountain Regional Center to accept and retain Level 4I residents.
Current census was 5. 3 out 5 residents were out at their respective day program at this time.
The applicant has an active administrator certificate #7018697935 and expires on 04/22/2025.
This facility also has an centralized ansel system, centralized carbon monoxide detectors, and smoke detectors that were serviced on 03/27/2024.
Fire extinguishers located throughout the facility were serviced by Nor Cal Fire on 05/03/2024 and is in compliance at this time.
A tour of the facility was conducted.
A tour of the living, dining room, and other rooms intended for resident use was toured. Furniture was observed to be in good repair and meet the residents needs.
A tour of the kitchen was toured. LPA observed a sufficient supply of 2 day perishable and 7 day non-perishable food supply. A medication cabinet was observed. Along with the applicant, LPA reviewed and compared medication with medication dispensing logs.
A tour of 4 resident bedrooms were conducted. Furniture and furnishings were observed to meet the residents needs at this time.
A tour of 3 bathrooms were conducted. Hot water temperature was measured to ensure within the regulatory standards of 105-120 degrees.
A first aid cabinet was identified. A linen closet was identified. LPA observed a sufficient amount of linens to meet the residents needs.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2024
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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: LAGUNA CARE HOME
FACILITY NUMBER: 392701448
VISIT DATE: 10/15/2024
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A tour of the backyard was conducted with no hazards present. Perimeter fence and gates were observed to be stable and in good repair.
A tour of the garage was conducted. Additional supplies, washer and dryer were identified.
Toxins, cleaning supplies, and other supplies were locked and made inaccessible.

Based on the observations made during this visit, this applicant has passed the pre-licensing inspection.
Component III was reviewed with this applicant.

An exit interview was conducted and a copy of this report was provided to the applicant at the end of this visit.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2024
LIC809 (FAS) - (06/04)
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