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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700886
Report Date: 06/23/2022
Date Signed: 06/23/2022 02:43:08 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/03/2022 and conducted by Evaluator Tung Truong
COMPLAINT CONTROL NUMBER: 27-AS-20220503081127
FACILITY NAME:GARDENS AT LAGUNA SPRINGS MEMORY CARE, THEFACILITY NUMBER:
342700886
ADMINISTRATOR:MARY KEATONFACILITY TYPE:
740
ADDRESS:9750 LAGUNA SPRINGS DRIVETELEPHONE:
(916) 667-3167
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY:70CENSUS: 31DATE:
06/23/2022
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Mary KeatonTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Resident missed medications
Staff did not follow physician's orders
INVESTIGATION FINDINGS:
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On 06/23/22 at 1:30 pm, Licensing Program Analyst (LPA) Tung Truong arrived at the facility unannounced to conclude the investigation of the above allegations and to deliver the findings. LPA met with Administrator Mary Keaton and explained the purpose of the visit.

Throughout the course of the investigation, LPA Truong conducted interviews and reviewed facility documents. Based on the interviews and reviewed of records, it was learned that on 4/18/2022, resident R1 had an unwitnessed fall. Staff (S2) who found R1 stated she can’t recall if EMS instructed not to give meds to R1. S2 stated R1 usually get his insulin around 8 am. S2 stated R1 left the facility at 8:05 and did not get his morning insulin.

Continued on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 27-AS-20220503081127
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: GARDENS AT LAGUNA SPRINGS MEMORY CARE, THE
FACILITY NUMBER: 342700886
VISIT DATE: 06/23/2022
NARRATIVE
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It was also learned that on 4/29/2022, resident (R1) was given insulin at approximately two hours late by staff (S3). LPA Truong was unable to contact S3 for a statement. According to staff (S1) and (S4), doctor’s order to give insulin at mealtime of 8am, 12pm, and 5pm. Staff (S1, S2 and S4) stated that R1 received his insulin two hours late on 4/29/22. Due to the above noted information, staff S3 did not provide insulin to R1 at the prescribed time by physician’s order.

As a result of this investigation, the Department finds this allegation to be Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiency cited on the LIC 9099-D, per Title 22 Regulations.

An exit interview was conducted, a copy of the report, LIC 9099-D and appeal rights were provided.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20220503081127
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: GARDENS AT LAGUNA SPRINGS MEMORY CARE, THE
FACILITY NUMBER: 342700886
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/24/2022
Section Cited
CCR
87465(a)(1)
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87465(a)(1) A plan for incidental medical and dental care shall be developed by each facility...The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.
This requirement is not met as evidenced by:
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Facility will obtain medication administration training from a certified trainer outside the facility. All staff who provide medication administration will be required to complete training and pass an evaluation. Licensee will submit documentation of training to LPA by the POC due date.
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Based on interview and record review, the licensee did not ensure meds were provided to resident. Resident R1 missed his morning insulin dose when leaving the facility. This posed an immediate health and safety risk to residents in care
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Type A
06/24/2022
Section Cited
CCR
87465(c)(2)
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87465(c)(2) Incidental Medical and Dental Care. Once ordered by the physician the medication is given according to the physician's directions.
This requirement is not met as evidenced by:
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Licensee/Administrator shall submit a plan stating how staff will receive additional training in medications, charting, and ensure the Health and Welfare of the residents at the facility. Send via email to LPA by plan of correction date: 6/24/22.
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Based on LPA’s documentation review. The licensee did not ensure meds were given according to the physician's directions. Facility staff did not ensure insulin is provided timely to resident as prescribed by physician’s order. Resident R1 was given insulin two hours late. This posed an immediate health and safety 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.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/03/2022 and conducted by Evaluator Tung Truong
COMPLAINT CONTROL NUMBER: 27-AS-20220503081127

FACILITY NAME:GARDENS AT LAGUNA SPRINGS MEMORY CARE, THEFACILITY NUMBER:
342700886
ADMINISTRATOR:MARY KEATONFACILITY TYPE:
740
ADDRESS:9750 LAGUNA SPRINGS DRIVETELEPHONE:
(916) 667-3167
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY:70CENSUS: 31DATE:
06/23/2022
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Mary KeatonTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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2
3
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5
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9
Staff falsified medication records
INVESTIGATION FINDINGS:
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On 06/23/22 at 1:30 pm, Licensing Program Analyst (LPA) Tung Truong arrived at the facility unannounced to conclude the investigation of the above allegations and to deliver the findings. LPA met with Administrator Mary Keaton and explained the purpose of the visit.

Throughout the course of the investigation, LPA conducted interviews and reviewed facility documents. Based on the interviews and reviewed of records, there was not enough evidence to prove that staff falsified medication records. Staff (S1) and (S2) stated they did not falsified medication records. Records show that R1 didn’t receive insulin on the day he went to the hospital for an evaluation after a fall.

Continued on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20220503081127
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: GARDENS AT LAGUNA SPRINGS MEMORY CARE, THE
FACILITY NUMBER: 342700886
VISIT DATE: 06/23/2022
NARRATIVE
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As a result of this investigation, the Department finds the allegations above to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

An exit interview was conducted, and a copy of this report was provided.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5