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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700886
Report Date: 03/24/2022
Date Signed: 03/24/2022 07:13:31 PM

Document Has Been Signed on 03/24/2022 07:13 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:GARDENS AT LAGUNA SPRINGS MEMORY CARE, THEFACILITY NUMBER:
342700886
ADMINISTRATOR:IRENE CHARNELLFACILITY TYPE:
740
ADDRESS:9750 LAGUNA SPRINGS DRIVETELEPHONE:
(916) 667-3167
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY: 70CENSUS: 30DATE:
03/24/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
05:00 PM
MET WITH:Irene Charnell, Executive Director
Jennifer Valcazar, Office Manager		TIME COMPLETED:
07:00 PM
NARRATIVE
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On 3/24/2022 at 1:30 pm, Licensing Program Analysts (LPAs) Tung Truong and Avelina Martinez conducted an unannounced case management visit. LPAs met with Executive Director Irene Charnell, Office Manager Jennifer Valcazar and explained the purpose of today's visit.

During this visit, LPAs discovered during review of the Licensing Information System (LIS) Facility Personnel Report that staff S1, S2 and S3 (LIC 811) are not fingerprint cleared as required. In addition, the facility does not have a certified administrator associated to the facility.

The following documents were requested to be submitted to LPA:

-Designation of Administrative Responsibility (LIC 308)
-Administrator Certificate
-LIC501

Per California Code of Regulations, Title 22, the following deficiencies are cited. See LIC 809-D. Exit interview was held, a copy of the report was given and appeal rights provided.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE: DATE: 03/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/24/2022
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 03/24/2022 07:13 PM - It Cannot Be Edited


Created By: Tung Truong On 03/24/2022 at 06:15 PM
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: GARDENS AT LAGUNA SPRINGS MEMORY CARE, THE
FACILITY NUMBER: 342700886

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/25/2022
Section Cited
CCR
87355(e)(1)

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Criminal Record Clearance. Prior to working, residing or volunteering in a licensed facility, all individuals subject to a criminal record review shall obtain a clearance or criminal record exemption.
This requirement was not met by as evidenced by:
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Effective immediately, the Administrator shall ensure that S1 and S2 do not work until fingerprint clearance and association is obtained. Administrator shall send proof to CCL prior to allowing S1 and S2 to work at this facility and shall send proof to CCL of fingerprint clearance and association. Staff S3 has been associated during this visit.
Civil penalties have been assessed.
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Based on Licensing Information System (LIS) reviewed staff S1, S2 and S3 are not currently fingerprint cleared or associated to the facility. This posed an immediate health and safety risk to residents in care.
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Type A
03/25/2022
Section Cited
CCR87405

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Administrator - Qualifications and Duties (a) All facilities shall have a certified administrator.
This requirement was not met by as evidenced by:
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Facility agrees to provide LPA by 3/25/2022 the following: LIC 200, LIC 308, LIC 501, administrator schedule, and certificates.
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LPAs reviewed administrators’ documentation and Licensing Information System (LIS), the facility did not have a certified administrator. This poses an immediate health, safety, and personal rights risk to residents in care.
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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:Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME:Tung Truong
LICENSING EVALUATOR SIGNATURE:
DATE: 03/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2022


LIC809 (FAS) - (06/04)
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