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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700350
Report Date: 06/01/2022
Date Signed: 06/01/2022 03:53:56 PM


Document Has Been Signed on 06/01/2022 03:53 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: 5DATE:
06/01/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:55 PM
MET WITH:Marlene Duncan, caregiver TIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to issue an additional deficiency discovered during a recent complaint investigation. LPA met with Marlene Duncan, caregiver, who contacted the Administrator, Lani, by phone. LPA spoke to Administrator and explained purpose of inspection. LPA also observed caregiver, Fredricka Quarrie to be present.

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: KN95 mask. LPA observed (5) residents to be napping/awake in their rooms at the start of the inspection. (1) resident was sent to the ER this morning and will be returning today.

During the investigation of complaint 25-AS-20220128094750, it was discovered that resident records were not maintained for resident (R1) following resident's stay at the facility from 1/22/22 - 1/24/22. Administrator indicated that resident's responsible person requested that resident's records be shredded and disposed of due to containing personal information.

LPA discussed with Administrator today the requirement to maintain resident records of reach resident for a minimum of (3) years, even if a resident or their representative requests they be shredded. LPA and Administrator discussed possibly redacting personal information such a social security number on the copies maintained at the facility.

The additional deficiencies issued on 5/26/2022 were cleared during today's inspection as documentation of training was received by the Department on 5/27/22.

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 to be e-mailed to the 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: 06/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2022
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 06/01/2022 03:53 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: 06/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/15/2022
Section Cited

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87506 Resident Records (e) Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident.This requirement is not met as evidenced by:
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Based on interview conducted with Administrator, records for resident (R1) were not maintained at the facility following resident moving out on 1/24/22, which posed 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: 06/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2022
LIC809 (FAS) - (06/04)
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