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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003430
Report Date: 07/16/2024
Date Signed: 07/16/2024 11:54:07 AM

Document Has Been Signed on 07/16/2024 11:54 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 STAR HOMEFACILITY NUMBER:
347003430
ADMINISTRATOR/
DIRECTOR:		ANGELES, JUNEFACILITY TYPE:
740
ADDRESS:8720 LAGUNA STAR DRIVETELEPHONE:
(916) 684-8787
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 6CENSUS: 6DATE:
07/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Romaine FelixTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct an annual inspection. LPA Moleski met with facility administrator Romaine Felix and explained the purpose of the visit.

LPA Moleski reviewed four resident files (R1-R4) and three staff files (S1-S3).

LPA Moleski toured the facility with Felix and inspected common areas, the kitchen, bedrooms, bathrooms, and backyard areas. Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 69 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 90 degrees Fahrenheit, which is below the required range of 105 and 120 degrees.

While touring the facility LPA Moleski and Felix observed medications left unlocked in a kitchen drawer. The medication were removed.

LPA Moleski observed first aid supplies, a fully-charged and up-to-date fire extinguisher, and carbon monoxide/smoke detectors. LPA Moleski observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. 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 one resident (R4).

This facility is being cited per 22 CCR Sections 87303(e)(2) and 87465(h)(2). An exit interview was held with Felix. Appeal rights and a copy of this report was left with Felix.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE: DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/16/2024
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 07/16/2024 11:54 AM - It Cannot Be Edited


Created By: Vincent Moleski On 07/16/2024 at 11:43 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: LAGUNA STAR HOME
FACILITY NUMBER: 347003430

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/16/2024

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, medications were left in an unlocked drawer in the kitchen, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/17/2024
Plan of Correction
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Facility staff locked up the medications during this visit. This POC will be cleared.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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4
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: 07/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/16/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 07/16/2024 11:54 AM - It Cannot Be Edited


Created By: Vincent Moleski On 07/16/2024 at 11:43 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: LAGUNA STAR HOME
FACILITY NUMBER: 347003430

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, water temperature was not within the required range, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/23/2024
Plan of Correction
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License shall retest and provide LPA Moleski a photo of the new reading.
vincent.moleski@dss.ca.gov
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
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: 07/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/16/2024


LIC809 (FAS) - (06/04)
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