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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700350
Report Date: 02/09/2022
Date Signed: 02/09/2022 04:07:10 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:
02/09/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Denise Hall, caregiver TIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a follow up case management inspection. LPA met with Denise Hall, caregiver (S3) who contacted the Administrator, Leilani, by phone. LPA spoke to Administrator and explained reason for visit. Caregiver confirmed there are (6) residents currently, and there is (1) resident on hospice. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols and completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the community. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 mask. LPA observed (6) residents to be napping/awake in their rooms.

LPA conducted an inspection on 2/2/2022 at the facility, and it was learned following the inspection that staff (S1 and S2), who were present during the inspection, did not have fingerprint clearance prior to starting their employment at the facility. LPA followed up by phone with the Administrator on 2/7/2022 to advise of the requirement that staff be fingerprint cleared before being allowed to work at the facility. Administrator advised that S1 would be having fingerprints taken that day, on 2/7/2022. Administrator provided LPA with electronic documentation during today's inspection that S1 is currently cleared and associated to the facility effective yesterday, 2/8/22. Administrator stated that S2 chose not to have fingerprints taken and no longer works for the facility. Administrator confirmed that both S1 and S2 worked at the facility starting on/around January 2022. Interview conducted with S2 on 2/2/2022 revealed that S2 worked at the facility for approximately 6 weeks. S1 did not provide an exact start date but confirmed S1 was working at the facility on/around 1/22/2022 when interviewed on 2/2/2022. Staff S3, who is fingerprint cleared is associated to this facility effective 2/9/2022. S3 was previously working for a related facility.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiency (1) is cited today. See 809D for deficiency cited.
Exit interview by phone with Administrator. Authorization given to caregiver to sign. Copy of report and appeal rights emailed to Administrator following today's inspection.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2022
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 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: SPRING GLEN ELDERLY CARE VILLA
FACILITY NUMBER: 342700350
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/10/2022
Section Cited

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87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:

(1) Obtain a California clearance or a criminal record exemption as required by the Department.
This requirement is not met as evidenced by:
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Based on interviews conducted and documentation reviewed, the Licensee did not ensure that staff (S1/S2) obtained a criminal record clearance prior to working, residing, volunteering at the facility, which posed an immediate health and safety risk to residents in care.
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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: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2022
LIC809 (FAS) - (06/04)
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