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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347003430
Report Date: 07/21/2021
Date Signed: 08/02/2021 04:33:49 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/19/2021 and conducted by Evaluator Tirzah Hubbard
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20210719140643
FACILITY NAME:LAGUNA STAR HOMEFACILITY NUMBER:
347003430
ADMINISTRATOR:ANGELES, JUNEFACILITY TYPE:
740
ADDRESS:8720 LAGUNA STAR DRIVETELEPHONE:
(916) 684-8787
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY:6CENSUS: 6DATE:
07/21/2021
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:June AngelesTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Licensee failed to have sufficient staffing per Program Design.
INVESTIGATION FINDINGS:
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On 7-21-21 Licensing Program Analysts (LPA)s Tirzah Hubbard and Charlie Yang conducted an unannounced visit to discuss complaint allegations and deliver complaint findings. LPAs met with June Angeles the Licensee. LPAs toured the facility physical plant to observe the facility in ratio for the day at 3:30pm.

Based on observation and interviews it was learned that two staff were required at all times to be present at this facility per program design. It was learned on 7-15-21 that there were only one staff present. As a result this facility did not maintain the required staff ratio of two. This facility was deficient, Therefore this complaint is SUBSTANTIATED.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no violations were observed during this visit. Deficiencies are cited on the 809D. An exit interview was conducted with June Angeles via telephone and a copy of this report was provided and signature confirms receiving these documents.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Tirzah Hubbard
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 27-AS-20210719140643
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 STAR HOME
FACILITY NUMBER: 347003430
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/21/2021
Section Cited
CCR
85605(b)
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Care & Supervison
85605(b) (Zero Tolerance) The licensee shall employ staff as necessary to ensure provision of care and supervision to meet client needs.

This was not met as evidence by:
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Licensee will ensure the facility is fully staff. Licensee stated that all staff will be trained no less then one hour in duration with proof of completed training of care and supervision to be submitted into CCL by the due date.
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Licensee did not ensure the facility were fully staff and present during shift which poses an immediate health, safety and personal rights risk to persons in care.
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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.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Tirzah Hubbard
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2021
LIC9099 (FAS) - (06/04)
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