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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700350
Report Date: 05/26/2022
Date Signed: 05/26/2022 06:54:26 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/28/2022 and conducted by Evaluator Sabrina Calzada
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20220128094750
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
UNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Fredricka Quarrie and Maureen Williams, caregivers TIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Resident not administered medication as prescribed.
Facility did not assess resident prior to admission.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to complete and deliver findings to a complaint received on 1/28/2022. LPA met with Fredricka Quarrie, Maureen Williams, Marlene Duncan, caregivers, who contacted the Administrator, Lani, by phone. LPA spoke to Administrator and explained reason for visit. Administrator stated she is not able to be at the facility during today's inspection but would request that Co-Administrator, Glenn, stop by and caregivers could assist LPA also. Co-Administrator, Glenn Bilog, arrived at facility around 3:30 pm. Caregivers confirmed there are (6) residents currently, and there are (0) residents 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 at the start of the inspection.

The results of the investigation are as follows:
cont on 9099C(1)..
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
Control Number 25-AS-20220128094750
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 05/26/2022
NARRATIVE
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During the investigation, LPA interviewed (2) Administrators and (3) caregivers and a family member and reviewed documentation pertaining to medication administration for (3) current residents. Resident (R1) moved to the facility on 1/22/22 around the afternoon time and moved out on 1/24/22 early in the morning.

Allegation: Resident not administered medication as prescribed.
Allegation is resident (R1) is required to take melatonin once a day at 10:00pm but instead was being administered two melatonin at noon.

Interview with (2) Administrators indicated that resident (R1) refused medications starting on Sunday, 1/24/22 and would only accept from family members. One staff stated "(R1) refused medications- she spit them out- we put them in applesauce and she still spit them out". A second staff stated he was not aware of any medication issues, and a third staff stated "I never gave her medications- I was off work".Administrator confirmed there is no documentation on file as resident's family requested that any documentation be shredded after resident moved out and the placement agency took some documents also.

LPA and staff (S1) reviewed medications for (3) residents (R2-R4) on 5/26/2022, including physician's orders, Centrally Stored Medication Record (LIC622) and Medication Administration Record (MAR) for May 2022. It was determined that resident (R2) had not received Docusate on 5/26/22, due to waiting for a refill, but had received it from 5/1/22- 5/25/22.

For resident (R3), Klor-Con-8-MEQ and Docusate 200mg were last administered on 5/25/22 in the morning, due to waiting on a refilled supply. Additionally, LPA observed an empty bottle of Atorvastatin-Calcium 40 mg, filled on 8/16/2021, and an opened bottle of Melatonin 10mg, to be stored with R3's current medications; Neither medication was listed on the May 2022 MAR and prescription orders, dated 8/25/2021 show that each medication is scheduled to be taken once daily.

For resident (R4), LPA and S1 counted 23 tablets of PRN Alprazolam 0.5 mg, filled on 5/15/22, and determined that 7 tablets were administered since 5/15/22; however, there is no documentation on file as required. New orders were written on 5/24/22 to discontinue Alprazolam and start PRN Haloperidol 2 mg. Administrator confirmed that the medication Alprazolam, was given but not documented.

cont on 9099C(2)..
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
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 25-AS-20220128094750
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 05/26/2022
NARRATIVE
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Based on information obtained, LPA finds the allegation to be SUBSTANTIATED- A finding that the allegation is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Allegation: Facility did not assess resident prior to admission.

Allegation is resident (R1) was not physically assessed prior to residing at the facility and placement agency and Licensee agreed to accept resident to move in.

Administrator stated on 2/2/22 that she did not evaluate resident in person, prior to admission, and asked skilled nursing for paperwork, including resident's physician's report. Administrator further stated that she talked to resident's daughter before admitting her. Administrator confirmed there was also no paperwork kept on file after resident moved out. LPA was not able to contact placement agency representative to confirm the pre-appraisal process used.

Based on information obtained, LPA finds the allegation to be SUBSTANTIATED- A finding that the allegation is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Per California Code of Regulation, Title 22, Division 6, Chapter 8, the following (2) deficiencies are issued on the 9099D pages.

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
LIC9099 (FAS) - (06/04)
Page: 6 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/28/2022 and conducted by Evaluator Sabrina Calzada
COMPLAINT CONTROL NUMBER: 25-AS-20220128094750

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
UNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Fredricka Quarrie and Maureen Williams, caregivers TIME COMPLETED:
05:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not provide accurate dosage of medication to residents.
Staff administered incorrect medications.
INVESTIGATION FINDINGS:
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During the investigation, LPA interviewed (2) Administrator, (3) caregivers and a family member and reviewed documentation pertaining medication administration for (3) current residents.

The results of the investigation are as follows:

Allegation: Staff did not provide accurate dosage of medication to residents.

Allegation asserts that resident (R1) is required to take melatonin once a day at 10:00pm but was being administered two melatonin at noon.

Both Administrators stated and staff stated that resident (R1) refused to take medications by staff but would accept them from a family member(s). One Administrator stated that he is aware that resident was prescribed melatonin but she did not allow staff to administer her medications.
cont on 9099C(1)...
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 25-AS-20220128094750
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 05/26/2022
NARRATIVE
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9099C(1).. Resident's family member said one Administrator stated there were (2) melatonin in a picture family member texted to Administrators but could not explain why there were (2) "pre-poured" for resident.
Family member also stated that when she visited on Sunday, 1/23/22, in the morning, R1 was asleep in the chair in the living room and staff stated "I guess she took her medications". Another staff stated that resident woke him up at 4 am and wouldn't sleep.

Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED- meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Allegation: Staff administered incorrect medications.
    Allegation is when R1's family member requested to see R1's medication. RP stated staff (S2) brought out a white basket full of medications with R3's name on it and none of the medications belonged to R1. It is unclear how long R1 was being administered R3's medications.

    LPA interviewed staff (S2) and asked if there was a medication mix-up with R1's medications and another resident's medications. S2 stated "No, there was not a mix-up with the medications"- the "Medications are already in a pocket", ready to administer. S2 showed LPA the small walk-in closet with shelves where resident medications and binders are kept. LPA observed multiple residents' medications, each in a labeled basket. LPA asked how S2 may have grabbed the wrong basket if each basket has a name on it. S2 then spoke quickly, stating that during the video call R1's family member pointed to the white basket and said "that basket" when asked which basket has R1's medications. S2 further stated that R1 took medications once only, from 1/22/22 through 1/24/22, when her family member gave them to her. Resident moved out on 1/24/22.

    Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED- meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

    Exit interview. Copy of report 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
    LIC9099 (FAS) - (06/04)
    Page: 3 of 6
    Control Number 25-AS-20220128094750
    STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

    COMPLAINT INVESTIGATION 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
    06/10/2022
    Section Cited
    CCR
    87465(a)(4)
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    		87465 Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
    (4) The licensee shall assist residents with self-administered medications as needed.
    This requirement is not met as evidenced by:
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    		Licensee/Administrator agree to conduct medication management training to all staff, including correct documentation on MAR, LIC622, PRN, refill process.
    Administrator agrees to audit the remaining (3) resident files to ensure there are no discrepancies between doctor orders and medication being administered.
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    		Based on documentation review, medications were not administered for residents, R2 and R3, per physician's orders, as medication exhausted before a refill was obtained. Additionally, MAR does not document that R3 received Atorvastatin-Calcium 40 mg, or Melatonin 10mg as ordered, which poses a potential health and safety risk to residents in care.
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    		Documentation of training- including topics discussed and staff who attended to be faxed to the department by 6/10/22.
    Type B
    06/10/2022
    Section Cited
    CCR
    87457(c)(1)
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    		(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.

    (1) The appraisal shall include, at a minimum, an evaluation of the prospective resident's functional capabilities, mental condition and an evaluation of social factors as specified in Sections 87459, Functional Capabilities and 87462 Social Factors.This requirement is not met as evidenced by:
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    		Licensee/Administrator agrees to read Regulation 87457 and provide a signed statement to the department that it is undestood. Due by 6/10/22.
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    		Based on interview with Administrator, the Licensee did not ensure that resident (R1) was evaluated in person prior to admission on 1/22/22, 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: 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
    LIC9099 (FAS) - (06/04)
    Page: 5 of 6