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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701137
Report Date: 02/13/2023
Date Signed: 02/13/2023 01:29:39 PM

Document Has Been Signed on 02/13/2023 01:29 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:LAGUNA WOODSFACILITY NUMBER:
342701137
ADMINISTRATOR:KANG, MARIAFACILITY TYPE:
740
ADDRESS:10035 PIANELLA WAYTELEPHONE:
(916) 833-1493
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY: 6CENSUS: 5DATE:
02/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Jennylind Duran - AdministratorTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced Required 1 Year Annual Inspection Visit. Prior to entering the facility. LPA explained purpose of visit to administrator. LPA was screened for COVID-19 symptoms and temperature taken prior to entering the facility. Administrator Certificate expires 5/23/2024.

LPA and administrator toured and inspected the physical plant inside and outside to ensure there were no health and safety concerns. LPA observed there were five (5) 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 113.5 degrees Fahrenheit which is within the required range of 105-120 degrees Fahrenheit. The temperature inside the facility measured at 72.4 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. Fire extinguishers were last serviced 3/16/2022. Smoke and carbon monoxide detectors are in compliance with fire safety.

LPA reviewed and compared resident medication vs. resident medication logs. LPA reviewed three (3) resident and two (2) staff files, including criminal record clearances. LPA reviewed Fingerprint clearance and associations to the facility. First aid kit was checked and is complete.

LPA received the following updated documents on today's date:
LIC 308, LIC 610-E, Liability insurance Certificate, and Administrator Certificate.

No deficiencies cited from the California Code of Regulations, Title 22, and California Health and Safety Code.

Exit interview held with Administrator and a copy of report given at the conclusion of the visit.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2023
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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