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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701138
Report Date: 05/13/2024
Date Signed: 05/13/2024 12:10:19 PM

Document Has Been Signed on 05/13/2024 12:10 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:COMFORTS OF HOME LAGUNA PARKFACILITY NUMBER:
342701138
ADMINISTRATOR/
DIRECTOR:		KANG, MARIAFACILITY TYPE:
740
ADDRESS:5721 LAGUNA PARK DRIVETELEPHONE:
(916) 833-1493
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 6CENSUS: 6DATE:
05/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Maria KangTIME VISIT/
INSPECTION COMPLETED:
12:20 PM
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct an annual inspection. LPA Moleski met with Maria Kang and explained the purpose of the visit.

LPA Moleski reviewed six resident files (R1-R6) and three staff files (S1-S3).

LPA Moleski toured the facility with Kang and inspected common areas, the kitchen, bedrooms, bathrooms, and backyard areas. While touring the kitchen, LPA Moleski observed several injectable medications located in the facility's refrigerator. The medications were not locked or secured. Staff secured the medications in a locked container during this visit.

Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 68 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 116 degrees Fahrenheit, which is within the required range of 105 and 120 degrees.

LPA Moleski observed first aid supplies, a fully-charged and up-to-date fire extinguisher, and carbon monoxide/smoke detectors. LPA Moleski observed a locked cabinet for the storage of medication. LPA Moleski observed locked cabinets for the storage of cleaning solutions and knives.

LPA Moleski interviewed two staff members (S1-S2) and two residents (R2, R5).

This facility is being cited per 22 CCR Section 87465(h)(2). An exit interview held with Kang. Appeal rights and a copy of this report was left with Kang.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE: DATE: 05/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/13/2024
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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Document Has Been Signed on 05/13/2024 12:10 PM - It Cannot Be Edited


Created By: Vincent Moleski On 05/13/2024 at 11:59 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: COMFORTS OF HOME LAGUNA PARK
FACILITY NUMBER: 342701138

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, refrigerated medications were not secured and locked, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/14/2024
Plan of Correction
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Staff locked up the medication during this visit. This POC will be cleared.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Stephen Richardson
LICENSING EVALUATOR NAME:Vincent Moleski
LICENSING EVALUATOR SIGNATURE:
DATE: 05/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2024


LIC809 (FAS) - (06/04)
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