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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700886
Report Date: 12/06/2024
Date Signed: 12/06/2024 02:52:55 PM

Document Has Been Signed on 12/06/2024 02:52 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:GARDENS AT LAGUNA SPRINGS MEMORY CARE, THEFACILITY NUMBER:
342700886
ADMINISTRATOR/
DIRECTOR:		RAMIREZ, GUADALUPEFACILITY TYPE:
740
ADDRESS:9750 LAGUNA SPRINGS DRIVETELEPHONE:
(916) 667-3167
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY: 70CENSUS: 44DATE:
12/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Guadalupe Ramirez TIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Christina Valerio arrived to the facility unannounced to conduct an annual required inspection. LPA Valerio met with front desk staff, and explained the purpose of the visit. LPA was shortly met by Administrator Guadalupe Ramirez.

LPA Valerio and Administrator toured the facility to ensure compliance of Title 22 regulations. LPA Valerio observed common areas, which included the lobby area, two lounge areas, an activity room, dinning hall, and hallways. All areas were observed to be clean, fully furnished, free from debris, and free from odors. Residents were observed walking in the hallways, sitting in common areas, or engaging with staff members. LPA Valerio checked one restroom located in the common area. The bathroom was observed to be sanitary, have hygiene supplies, and stocked with toilet paper and paper towels. Hot water in the bathrooms were measured and determined to provide hot water within the regulatory range of 105.0 - 120.0 degrees F. LPA Valerio toured multiple resident bedrooms. Bedrooms, which include a bathroom, were observed to be fully furnished, free from odors of incontinence, and clean. Toxins, sharps, and medications were observed to be locked and inaccessible to residents in care. Fire extinguishers were observed to be within compliance and fully charged. All emergency exits were free from obstructions. LPA observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises

LPA Valerio reviewed four (4) resident files. Resident files were observed to be up to date with required annual documentation. LPA Valerio reviewed four (4) staff files. Staff files were observed to have required annual training.

Continues on LIC 809 - C...
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2024
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: GARDENS AT LAGUNA SPRINGS MEMORY CARE, THE
FACILITY NUMBER: 342700886
VISIT DATE: 12/06/2024
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Continued from LIC 809

LPA Valerio followed up on an incident report submitted to the Regional Office on 11/28/24. After discussion with Administrator Guadalupe Ramirez, there are no health or safety concerns regarding the incident.

LPA Valerio obtained the following for the Regional Office Facility File: LIC 500 - Personnel Report, LIC 308, LIC 309 - Administrative Organization, LIC 610D, and copy of current Liability Insurance.

Per California Code of Regulations (CCR) - Title 222, no deficiencies were observed during today's visit. An exit interview was held, and a copy of the report was provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024
LIC809 (FAS) - (06/04)
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