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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003430
Report Date: 08/09/2022
Date Signed: 08/09/2022 04:07:31 PM

Document Has Been Signed on 08/09/2022 04:07 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
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:
08/09/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:58 PM
MET WITH:June AngelesTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Christina Valerio arrived to the facility unannounced to conduct a case management visit. LPA Valerio was met by Administrator June Angeles, and explained the purpose of the visit. Staff confirmed there are zero residents or staff that have displayed any signs or symptoms of COVID-19 in the last 10 days.

LPA toured the facility to ensure compliance with Title 22 regulations. LPA observed resident bedrooms, resident bathrooms, staff bedroom, and staff bathroom. Resident rooms were observed to have all necessary furniture and furnishings. Emergency exits were free from obstructions. Medication cabinets were locked. No health or safety concerns were observed.

LPA observed training files for staff. Staff certificates from 2022 were observed to be in the file.

LPA requested the following documentation: LIC 500, LIC 308, Daily Activity Schedule, Daily Showering Schedule, Completed Training from MD Quinley, Shout out Loud, and Career Smart, Proof of facility vehicle, updated liability insurance

Per California Code of Regulations (CCR's) - Title 22, Division 6, Chapter 8, no deficiencies were observed. Exit Interview was conducted with Administrator June Angeles, and a copy of report was left at facility.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/09/2022
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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