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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700350
Report Date: 07/22/2022
Date Signed: 07/22/2022 04:21:03 PM


Document Has Been Signed on 07/22/2022 04:21 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) 241-9536
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:6CENSUS: 4DATE:
07/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:55 PM
MET WITH:Teka Thomas, and Mureen Williams, caregivers TIME COMPLETED:
04:25 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual.
LPA met with Teka Thomas, and Mureen Williams, caregivers, and explained purpose of inspection.. Glenn Bilog, Administrator, arrived to the facility at approximately 3:15 pm. LPA observed (4) residents to be in their rooms at the start of the inspection. LPA was informed that (1) resident has been out of the facility for (2) weeks and will be returning next week. The facility is licensed for (6) non-ambulatory residents and has a hospice waiver for (3) residents. Currently, there are no residents on hospice. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols and confirmed the facility does not currently have any positive Covid-19 diagnoses. LPA was screened per Covid-19 precautionary measures upon entering the facility.and the following Personal Protective Equipment (PPE) was worn: N95 mask.

LPA and caregiver toured the interior and exterior of the facility including the common areas, resident bedrooms, resident bathrooms (3), kitchen,medication room, staff room and laundry. LPA observed the facility to be clean, in good repair and to have sufficient furniture and lighting.. LPA observed the bathrooms to have the necessary grab bars, non-skid flooring, paper towels- Admin to ensure hand-washing posters are placed near every sink. LPA observed sufficient 2+day perishable and 7+day non-perishable supply of food, locked sharps in the kitchen and locked toxins in the laundry room. LPA observed the inside temperature to be 80*F. Fire extinguisher was last serviced 7/27/2021- Administrator to complete annual servicing by 7/27/2022. Discussed vaccination status of residents/staff, eligibility for second boosters and visitation protocols. All staff are cleared/associated. Administrator certificate #6047388740- current through 2/16/2024. All required postings and various Covid posters are posted. LPA requested an updated copy of LIC500, LIC308, copy of the current liability insurance and the facility's Infection Control Plan by provided to the Department by 7/30/2022.

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: 07/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2022
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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