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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700244
Report Date: 03/24/2023
Date Signed: 03/24/2023 04:00:15 PM


Document Has Been Signed on 03/24/2023 04:00 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:SPRING VIEW GARDENS CARE HOMEFACILITY NUMBER:
342700244
ADMINISTRATOR:TAFTA, DANIELFACILITY TYPE:
740
ADDRESS:9964 SPRING VIEW WAYTELEPHONE:
(916) 273-2175
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY:6CENSUS: 4DATE:
03/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Daniel TaftaTIME COMPLETED:
04:20 PM
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) Tung Truong arrived at this facility unannounced to conduct an annual inspection visit. LPA met with Administrator Daniel Tafta and explained the purpose of the visit.

Administrator holds current certification #6043996740 and expires on 2/13/2023. Renewal application is currently pending. The facility is licensed for six (6) non-ambulatory residents and has hospice waiver for three (3). There are currently 4 residents of which 1 is on hospice in care. LPA toured the facility with facility house manager Mihaela Tafta to inspect the physical plant including but not limited to the common area, kitchen, pantry, dining area, resident bedrooms, resident bathrooms, laundry room, and outside courtyards of the facility to ensure compliance with Title 22 regulations.

LPA observed the facility is clean and in good repair. LPA observed sufficient furniture and lighting throughout the facility. LPA observed bedrooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition and properly maintained. The hot water temperature was observed to be 113.5 degrees Fahrenheit. Facility thermostat observed at 72 degrees Fahrenheit. Food supply is adequate for 2-day perishable and 7-day nonperishable. LPA observed knives and toxins to be locked away and inaccessible to clients. Smoke and carbon detectors were in good repair. Fire extinguisher and first aid kit was up to date. LPA checked medication cabinet and found medication to be locked away and inaccessible to residents. Proof of current liability insurance was observed. LPA also conducted the infection control domain tool.

Report continued on 809-C
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:
DATE: 03/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2023
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: SPRING VIEW GARDENS CARE HOME
FACILITY NUMBER: 342700244
VISIT DATE: 03/24/2023
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
26
27
28
29
30
31
32
The facility has submitted the Infection Control Plan to Licensing. Facility has routine symptom screening checks for clients, staff, and visitors. Hand Hygiene procedures have been implemented.

LPA requested resident and staff files for review. LPA reviewed (4) resident files and (3) staff files, including criminal record clearances. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility. LPA verified staff training for staff file reviews.

The following documents was obtained during today's visit:
(1) Resident roster
(2) LIC 500 Personnel Report
(3) LIC 308 Designation of Facility Responsibility
(4) LIC 610 Emergency Disaster Plan
(5) Proof of Current Liability Insurance

As a result of this visit, there were no deficiencies cited, per California Code of Regulations, Title 22 and Health and Safety Code. Exit interview was conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2