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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701137
Report Date: 02/14/2025
Date Signed: 02/14/2025 11:58:50 AM

Document Has Been Signed on 02/14/2025 11:58 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:LAGUNA WOODSFACILITY NUMBER:
342701137
ADMINISTRATOR/
DIRECTOR:		KANG, MARIAFACILITY TYPE:
740
ADDRESS:10035 PIANELLA WAYTELEPHONE:
(916) 833-1493
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY: 6CENSUS: 5DATE:
02/14/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Jennylind DuranTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 2/14/25 at 9:00am to conduct a Required - 1 Year inspection visit. LPA met with Karen Casila, Caregiver and Jennylind Duran, Administrator and explained the purpose of the visit. The facility is licensed for a capacity of 6 non-ambulatory residents of which 6 may receive hospice care services in rooms 1-6.

LPA observed residents participating in individual activities during this visit.
Administrator certificate expires 5/3/26. There is 1 person receiving hospice services during this visit.
The facility conducted a fire/disaster drill on 1/16/25 that was logged.
LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed kitchen, dining area, bedrooms and bathrooms, storage areas, laundry and lighting throughout the facility. 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 temperature inside the facility was observed to be at 72*F which is within the required range of 68-85*F. The hot water temperature was measured at 114.7 *F which is within the required range of 105-120*F. LPA observed fire extinguisher(s), smoke and carbon monoxide detectors, and central heating and air in the facility. LPA observed staff assisting residents with medication pass after which the centrally stored medications area was found to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide.
LPA reviewed files of 2 residents and 2 staff.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE: DATE: 02/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/14/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: LAGUNA WOODS
FACILITY NUMBER: 342701137
VISIT DATE: 02/14/2025
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Upon a file review the following items were discussed to be submitted with any changes annually:
Licensing fees-Current
Criminal Record Clearances LIS536-Current
Administrative Organization LIC309-Current
Designation of Administrative Responsibility LIC308-Submit
Personnel Report LIC500-Submit
Affidavit Regarding Client/Resident Cash Resources LIC400-NA
Surety Bond LIC402-NA
Facility Floor Plan/Plot Plan LIC999-Current
Fire Clearance (consistent with terms and limitations of license)-NA
Qualifications of Administrator/Facility Manager-Submit
Articles of Incorporation/Organization, Constitution and bylaws-NA
Partnership Agreement-NA
Control of Property-Submit
Emergency Disaster Plan LIC610-Submit
Plan of Operation (Restricted Health Care Plan)-NA
Admission Policies and Procedures-NA
Health Screening Report-Facility Personnel LIC503-NA
Bacteriological Analysis of Private Water Supply-NA
In-service Training Program-NA
Medication Procedures-NA
Transportation Procedures-NA
Job Description/Personnel Policies-NA
Exemptions/Waivers and Exceptions-Current
First aid/CPR certificates-Current
Liability Insurance-(if applicable)Submit
Infection Control Plan-Submit

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited during this visit. Exit interview held. A copy of todays’ report provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2025
LIC809 (FAS) - (06/04)
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