<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002806
Report Date: 09/07/2022
Date Signed: 09/13/2022 08:17:14 AM


Document Has Been Signed on 09/13/2022 08:17 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:SPRINGVIEW ELDERLY CAREHOMEFACILITY NUMBER:
315002806
ADMINISTRATOR:ARCEGA, LOVELIEFACILITY TYPE:
740
ADDRESS:5536 GRAHAM CT.TELEPHONE:
(916) 672-6945
CITY:ROCKLINSTATE: CAZIP CODE:
95677
CAPACITY:6CENSUS: 4DATE:
09/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Lovelie ArcegaTIME COMPLETED:
11:45 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 9/7/22 to conduct a Required- 1 Year Inspection utilizing the infection control domain. LPA met with staff and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 protocols, and self-screening questionnaire for symptoms of COVID-19 infection . LPA completed a facility risk assessment upon arrival. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA self screened upon entering the facility. LPA requested for staff to notify Administrator that LPA is present at the facility to conduct an annual inspection. .

LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, and backyard. In the areas toured LPA advised improvements. LPA and caregivers completed the infection control domain and facility was found to be in substantial compliance at this time.

LPA advised facility to increase documentation of daily screening for staff, residents and visitors, Staff receive N-95 fit testing. LPA advised creation of PRN authorization letters for all residents

LPA reviewed 4 of 4 resident files and they are complete and up to date.

LPA requested for documents: Resident roster, LIC 500 Including , Liability Insurance.

No deficiencies are being cited at this time. Exit interview conducted and copy of report left at the facility.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:
DATE: 09/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2022
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 1