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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003430
Report Date: 07/25/2022
Date Signed: 07/26/2022 08:53:44 AM

Document Has Been Signed on 07/26/2022 08:53 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
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:
07/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Romaine FelixTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced Required 1 Year Annual Inspection Visit. LPA met Administrator and explained purpose of today's visit.
Current census was 6 residents.

LPA and Administrator toured facility. Common areas were toured. Living area, recreation area, and all other areas intended for resident use were toured. It was observed that furniture and furnishings were in good repair and able to meet the needs of the residents at this time. resident bedrooms and restrooms was conducted. Resident bedroom furniture and furnishings were observed to be in good repair and able to meet the needs of the residents at this time.

Grab bars and non-skid mats/surfaces were observed to be present and in good repair at this time.
Kitchen area was toured. Food supply was reviewed for adequate 2 day perishable and 7 day nonperishable food quantities. Cabinets and drawers were opened and the contents were reviewed to make sure that there was an ample supply of cups, dishes, and all other items able to meet the needs of the residents at this time. Exterior grounds of this facility was toured. A review was conducted in regards to the facility perimeter fence and side gates. First aid kit was reviewed and observed to contain all required components at this time.
Fire extinguishers annual inspection by the local fire extinguisher company are in compliance at this time.

Hot water temperatures were measured in kitchen sink at 110.0 F which meets the requirement of allowed range of 105-120 degrees.
Laundry room was toured. It was observed that laundry detergents, cleaners, and cleaning supplies were locked and made inaccessible to the residents at this time. Garage area was toured.

Continue on 809-C
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 07/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/25/2022
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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: LAGUNA STAR HOME
FACILITY NUMBER: 347003430
VISIT DATE: 07/25/2022
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Continued from 809 - Page 2

A review of the medications for the residents, stored in a kitchen cabinet, was conducted. A review of the facility Medication Administration Record, dispensing log, and Control Book for narcotics was conducted.
Linen closet was reviewed and observed to contain a sufficient supply of sheets, blankets, and covers in order to properly meet the needs of the residents at this time.

A review of (3) facility personnel records was conducted and staff have current first aid certificates.
A review of (2) facility resident records was conducted and all required documents are in files per Community Care Licensing Regulations.

No deficiencies Per California Code of Regulations (CCR's) - Title 22, Division 6, Chapter 8
on today's date.

Exit Interview was conducted with Administrator. Copies of reports and appeal rights were left at facility.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2022
LIC809 (FAS) - (06/04)
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