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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701137
Report Date: 03/16/2022
Date Signed: 03/16/2022 11:37:59 AM

Document Has Been Signed on 03/16/2022 11:37 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:LAGUNA WOODSFACILITY NUMBER:
342701137
ADMINISTRATOR:KANG, MARIAFACILITY TYPE:
740
ADDRESS:10035 PIANELLA WAYTELEPHONE:
(916) 833-1493
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY: 6CENSUS: 6DATE:
03/16/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Maria Kang, Applicant
Jennylind Duran, Administrator		TIME COMPLETED:
11:50 AM
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Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced on 3/16/2022 at 8:50 AM to conduct a Pre-licensing CHOW inspection. Prior to entering the facility, LPA Truong called the facility and spoke to staff, who confirmed no residents or staff have had any symptoms of COVID-19 in the last 10 days. Upon LPAs arrival, Caregiver Rose Nadonza was present at facility and contacted current Administrator Jennylind Duran who arrived a bit later. LPA was screened for COVID-19 symptoms and temperature taken prior to entering the facility. LPA met with Applicant Maria Kang and current Administrator Jennylind Duran and explained the purpose of the visit. Applicant Maria Kang assisted with today’s visit.

Applicant Maria Kang holds a current certificate # 6020167740 which will expire on 09/02/2022. LPA toured and inspected the physical plant inside and outside with Applicant Maria Kang to ensure there were no health and safety concerns on 3/16/2022 at 9:20 AM. LPA observed there were six (6) residents in care at this time.

LPA observed the kitchen area, dining area, bedrooms, bathrooms, storage areas, and laundry area. LPA observed knives/sharps area to be locked. LPA observed required furniture, and lighting throughout the facility. The hot water temperature was measured at 118.9 degrees Fahrenheit which is within the required range of 105-120 degrees Fahrenheit. The temperature inside the facility measured at 70 degrees Fahrenheit which is within the required range of 68-85 degrees Fahrenheit. 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. The first aid kit was up to date.

Report continued on 809-C
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE: DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/16/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: LAGUNA WOODS
FACILITY NUMBER: 342701137
VISIT DATE: 03/16/2022
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LPA observed the centrally stored medication areas to be locked and made inaccessible to the residents at this time. LPA observed the fire extinguisher(s), smoke and carbon monoxide detector(s) in the facility were in good repair. LPA also conducted the inspection tool.

The facility had Covid-19 posting throughout the facility. The facility had a mitigation plan completed and provided for approval on 1/11/2022. The facility had one central entry point, and the facility had routine symptom screening checks for residents, staff, and visitors. The facility had a symptom check binder for staff, residents, and care staff. Hand Hygiene procedures have been implemented.

Based on a review of this facility during this pre-licensing visit, it was determined that this facility was found to be in compliance at this time.

Component III conducted - Licensure pending.

Per the California Code of Regulations, Title 22, Division 6, Chapter 6, no violations cited during this visit. Exit interview held, copy of report given.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022
LIC809 (FAS) - (06/04)
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