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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701137
Report Date: 12/20/2023
Date Signed: 12/20/2023 03:47:39 PM

Document Has Been Signed on 12/20/2023 03:47 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:LAGUNA WOODSFACILITY NUMBER:
342701137
ADMINISTRATOR:KANG, MARIAFACILITY TYPE:
740
ADDRESS:10035 PIANELLA WAYTELEPHONE:
(916) 833-1493
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY: 6CENSUS: 4DATE:
12/20/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:42 PM
MET WITH:Jennylind DuranTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to the facility to conduct a case management visit. LPA met with facility staff, and explained the purpose of the visit. LPA was later met by designated facility manager Jennylind Duran

On 12/13/23, the facility faxed a Death Report for Resident 1 to the Office of the Day Fax Line. On 12/18/23, LPA Valerio contacted the facility to request additional documentation. LPA left a voicemail; however, did not receive a call back.

LPA Valerio requested and reviewed facility files for Resident 1, which included R1's Admission Agreement, LIC 602, Appraisal/Needs and Service Plan, and supportive documentation.

LPA Valerio and staff Jennylind toured the facility. No health or safety concerns observed.

Per California Code of Regulations (CCR) - Title 22, no deficiencies were observed. 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: 12/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2023
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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