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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700350
Report Date: 05/26/2022
Date Signed: 05/26/2022 07:06:18 PM


Document Has Been Signed on 05/26/2022 07:06 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, 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:
05/26/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
05:00 PM
MET WITH:Glenn Bilog, Administrator TIME COMPLETED:
06:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to complete and deliver findings to a complaint investigation received on 1/28/2022. LPA met with Fredricka Quarrie, Maureen Williams, Marlene Duncan, caregivers, who contacted the Administrator, Lani, by phone. LPA met with Glenn Bilog, Co-Administrator, who arrived at the facility around 3:30 pm.

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 at the start of the inspection.

During the course of the investigation, the additional deficiency was observed as follows:

During a medication record review for resident (R1) on 5/26/22, it was determined that (7) tablets of a bottle of (30) of PTN Alprazolam 0.5 mg were administered to R1 from 5/15/22 through 5/26/22; however, there is no documentation to show on what days, times, etc as required per the regulation.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (1) deficiency is being cited on the 809D page.

Exit interview. Copy of report and appeal rights provided to Administrator.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:
DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2022
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 05/26/2022 07:06 PM - It Cannot Be Edited

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: 05/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/30/2022
Section Cited

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87465 Incidental Medical and Dental Care(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration provided all of the following requirements are met:
(3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record. This requirement is not met as evidenced by:
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Based on record review and interviews conducted, the Licensee did not ensure that the facility maintained a record of PRN medications administered for Alpharazolam 0.5mg for resident (R3), which poses a potential 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: 05/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2022
LIC809 (FAS) - (06/04)
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