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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700350
Report Date: 06/23/2021
Date Signed: 06/23/2021 02:07:42 PM

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:SPRING GLEN ELDERLY CARE VILLAFACILITY NUMBER:
342700350
ADMINISTRATOR:ARAGON, LEILANIFACILITY TYPE:
740
ADDRESS:5929 SPRING GLEN DRTELEPHONE:
(916) 844-7582
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:6CENSUS: 6DATE:
06/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Allan Gacusan- Lead StaffTIME COMPLETED:
02:12 PM
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Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced on 06/23/2021 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Lead Staff, Allan Gacusan, and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and completed a facility risk assessment at the facility with Lead Staff. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA were screened by facility staff upon entering the facility.

LPA toured the interior and exterior of the facility together with Lead Staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, five (5) resident bedrooms, three (3) bathrooms, kitchen, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and Lead Staff completed the infection control domain and facility was found to be in substantial compliance at this time.

LPA requested for Lead Staff to submit requested documents to Community Care Licensing by 06/29/21.
  • LIC 308 Designation of Administrative Responsibility
  • Administrator Certificate
  • LIC 610E Emergency Disaster Plan
  • LIC 500 Personnel Report

No deficiencies are being cited as a result of todays inspection.

Exit interview conducted and copy of report left at the facility.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021
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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