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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
342700350
Report Date:
06/19/2024
Date Signed:
06/19/2024 04:05:42 PM
Document Has Been Signed on
06/19/2024 04:05 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
SACRAMENTO NORTH ASC
,
9835 GOETHE ROAD, SUITE 100
SACRAMENTO
,
CA
95827
FACILITY NAME:
SPRING GLEN ELDERLY CARE VILLA
FACILITY NUMBER:
342700350
ADMINISTRATOR:
ARAGON, LEILANI
FACILITY TYPE:
740
ADDRESS:
5929 SPRING GLEN DR
TELEPHONE:
(916) 241-9536
CITY:
FAIR OAKS
STATE:
CA
ZIP CODE:
95628
CAPACITY:
6
CENSUS:
6
DATE:
06/19/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
11:20 AM
MET WITH:
Melissa Szeto, Administrator
TIME COMPLETED:
04:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility unannounced on 6/19/24 to conduct a Required-1 Year Inspection utilizing the inspection tool.
LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. There are five (5) bedrooms and two (2) bathrooms for resident use. LPA observed bedrooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition and properly maintained. Hot water temperature was observed to be 116 degrees F.
LPA checked the kitchen area for the ability to prepare and store food. LPA walked the perimeter of the care home and checked medication storage. LPA reviewed six (6) resident files and two (2) staff files. Facility has a current copy of certificate of liability insurance and LPA requested a copy.
As a result of today's inspection, deficiencies are being cited pursuant to California Code of Regulations, Title 22, Division 6, Chapter 8. Deficiencies are listed on 809-D pages. An immediate civil penalty per Health and Safety Code ยง 1548 in the amount of $500 for the date of 6/19/2024 is assessed for a violation that the department determines was a fire clearance violation.
Exit interview was conducted with Administrator. A copy of this report and appeal rights were provided. Signatures on these forms acknowledges receipt of these documents.
SUPERVISOR'S NAME:
Anthony Perez
TELEPHONE:
(323) 485-4915
LICENSING EVALUATOR NAME:
Michael Hood
TELEPHONE:
(916) 531-7341
LICENSING EVALUATOR SIGNATURE:
DATE:
06/19/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/19/2024
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
8
Document Has Been Signed on
06/19/2024 04:05 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
SACRAMENTO NORTH ASC
,
9835 GOETHE ROAD, SUITE 100
SACRAMENTO
,
CA
95827
FACILITY NAME:
SPRING GLEN ELDERLY CARE VILLA
FACILITY NUMBER:
342700350
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
06/19/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on LPA's observations, the facility did not ensure that storage for disinfectants, cleaning solutions, knives, and other hazardous items were locked and inaccessible to the residents at all times, including shed in backyard area, storage in kitchen area, and storage in laundry room, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
06/20/2024
Plan of Correction
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3
4
Facility will ensure that all storage for hazardous items is locked at all times and hazardous items are inaccessible to residents at all times. Administrator will complete a statement of understanding regarding regulation 87309 and submit statement to LPA by POC due date of 6/20/2024.
Type A
Section Cited
CCR
87465(a)(4)
Incidental Medical and Dental Care Services
(4) The licensee shall assist residents with self-administered medications as needed.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA's observations and records reviewed, facility did not ensure to document medications on Centrally Stored Medication Forms for all residents with some medications having no identifiable start date, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
06/20/2024
Plan of Correction
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3
4
Facility will ensure that Centrally Stored Medication Forms are completed for all residents to identify start dates for all medications administered. Administrator will complete a statement of understanding regarding regulation 87465 and submit statement to LPA by POC due date of 6/20/2024.
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:
Anthony Perez
TELEPHONE:
(323) 485-4915
LICENSING EVALUATOR NAME:
Michael Hood
TELEPHONE:
(916) 531-7341
LICENSING EVALUATOR SIGNATURE:
DATE:
06/19/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/19/2024
LIC809
(FAS) - (06/04)
Page:
2
of
8
Document Has Been Signed on
06/19/2024 04:05 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
SACRAMENTO NORTH ASC
,
9835 GOETHE ROAD, SUITE 100
SACRAMENTO
,
CA
95827
FACILITY NAME:
SPRING GLEN ELDERLY CARE VILLA
FACILITY NUMBER:
342700350
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
06/19/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on LPA's observations, facility did not ensure that medication room was locked and inaccessible to the residents at all times, and medications stored in refrigerator were accessible to the residents, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
06/20/2024
Plan of Correction
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2
3
4
Facility will ensure that medication room is locked and inaccessible to the residents at all times and medications stored in refrigerator are locked and inaccessible to the residents. Administrator will complete a statement of understanding regarding regulation 87465 and submit statement to LPA by POC due date of 6/20/2024.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
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:
Anthony Perez
TELEPHONE:
(323) 485-4915
LICENSING EVALUATOR NAME:
Michael Hood
TELEPHONE:
(916) 531-7341
LICENSING EVALUATOR SIGNATURE:
DATE:
06/19/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/19/2024
LIC809
(FAS) - (06/04)
Page:
3
of
8
Document Has Been Signed on
06/19/2024 04:05 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
SACRAMENTO NORTH ASC
,
9835 GOETHE ROAD, SUITE 100
SACRAMENTO
,
CA
95827
FACILITY NAME:
SPRING GLEN ELDERLY CARE VILLA
FACILITY NUMBER:
342700350
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
06/19/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on LPA's observation, facility did not ensure that debris was cleared from backyard area, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
07/01/2024
Plan of Correction
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4
Facility will ensure that debris is cleared from backyard area by POC due date of 7/1/2024.
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.
This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on LPA's observation and records reviewed, facility did not ensure that there was a staff member with CPR training at the facility at all times, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
07/05/2024
Plan of Correction
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Facility will ensure that there is at least one (1) staff member at the facility at all times with CPR training. Administrator will complete a statement of understanding regarding regulation 1569.618 and submit statement to LPA by POC due date of 7/5/2024.
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:
Anthony Perez
TELEPHONE:
(323) 485-4915
LICENSING EVALUATOR NAME:
Michael Hood
TELEPHONE:
(916) 531-7341
LICENSING EVALUATOR SIGNATURE:
DATE:
06/19/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/19/2024
LIC809
(FAS) - (06/04)
Page:
4
of
8
Document Has Been Signed on
06/19/2024 04:05 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
SACRAMENTO NORTH ASC
,
9835 GOETHE ROAD, SUITE 100
SACRAMENTO
,
CA
95827
FACILITY NAME:
SPRING GLEN ELDERLY CARE VILLA
FACILITY NUMBER:
342700350
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
06/19/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(a)
Other Provisions
(a) The administrator designated by the licensee pursuant to paragraph (11) of subdivision (a) of Section 1569.15 shall be present at the facility during normal working hours. A facility manager designated by the licensee with notice to the department, shall be responsible for the operation of the facility when the administrator is temporarily absent from the facility.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA's observations and records reviewed, facility did not ensure that an individual who can act as the Administrator or house manager was present at the facility during business hours, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
07/05/2024
Plan of Correction
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2
3
4
Facility will update an LIC 500 with Administrator and house manager hours and submit to LPA by POC due date of 7/5/2024.
Type B
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA's observations and records reviewed, facility did not ensure that health screenings were completed for all staff, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
07/05/2024
Plan of Correction
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2
3
4
Facility will complete a health screening for all care staff and maintain documentation at the facility at all times. Facility will submit documentation for health screenings to LPA by POC due date of 7/5/2024.
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:
Anthony Perez
TELEPHONE:
(323) 485-4915
LICENSING EVALUATOR NAME:
Michael Hood
TELEPHONE:
(916) 531-7341
LICENSING EVALUATOR SIGNATURE:
DATE:
06/19/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/19/2024
LIC809
(FAS) - (06/04)
Page:
5
of
8
Document Has Been Signed on
06/19/2024 04:05 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
SACRAMENTO NORTH ASC
,
9835 GOETHE ROAD, SUITE 100
SACRAMENTO
,
CA
95827
FACILITY NAME:
SPRING GLEN ELDERLY CARE VILLA
FACILITY NUMBER:
342700350
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
06/19/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(1)
Other Provisions
(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA's observations and records reviewed, facility did not ensure that staff received initial training and documentation for initial training was maintained at the facility, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
07/05/2024
Plan of Correction
1
2
3
4
Facility will ensure to complete initial training for all newly hired staff and maintain documentation for training at the facility at all times. Facility will complete initial training for any staff missing initial training and submit documentation for initial training to LPA by POC due date of 7/5/2024.
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:
Anthony Perez
TELEPHONE:
(323) 485-4915
LICENSING EVALUATOR NAME:
Michael Hood
TELEPHONE:
(916) 531-7341
LICENSING EVALUATOR SIGNATURE:
DATE:
06/19/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/19/2024
LIC809
(FAS) - (06/04)
Page:
6
of
8
Document Has Been Signed on
06/19/2024 04:05 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
SACRAMENTO NORTH ASC
,
9835 GOETHE ROAD, SUITE 100
SACRAMENTO
,
CA
95827
FACILITY NAME:
SPRING GLEN ELDERLY CARE VILLA
FACILITY NUMBER:
342700350
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
06/19/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA's observation and records reviewed, facility did not ensure that all care staff received first aid training, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
07/05/2024
Plan of Correction
1
2
3
4
Facility will ensure that all care staff receive training in first aid and documentation for training is maintained at the facility at all times. Facility will submit proof of first aid training for all care staff by POC due date of 7/5/2024.
Type B
Section Cited
CCR
87506(b)(16)
Resident Records
(b) Each resident's record shall contain at least the following information: (16) Records of resident's cash resources as specified in Section 87217, Safeguards for Resident Cash, Personal Property, and Valuables.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA's observations and records reviewed, facility did not ensure that all residents in care had a safeguard for personal property and valuables, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
07/05/2024
Plan of Correction
1
2
3
4
Facility will ensure to complete a safeguard of resident personal property and valuables and cash resources (if applicable) for all residents at the facility and maintain documentation at the facility at all times. Facility will submit safeguard forms to LPA by POC due date of 7/5/2024.
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:
Anthony Perez
TELEPHONE:
(323) 485-4915
LICENSING EVALUATOR NAME:
Michael Hood
TELEPHONE:
(916) 531-7341
LICENSING EVALUATOR SIGNATURE:
DATE:
06/19/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/19/2024
LIC809
(FAS) - (06/04)
Page:
7
of
8
Document Has Been Signed on
06/19/2024 04:05 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
SACRAMENTO NORTH ASC
,
9835 GOETHE ROAD, SUITE 100
SACRAMENTO
,
CA
95827
FACILITY NAME:
SPRING GLEN ELDERLY CARE VILLA
FACILITY NUMBER:
342700350
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
06/19/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203
87203 Fire Safety - All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA's observations, three fire exits (exits 3, 4, and 6) were obstructed, smoke alarm in room #3 was inoperable, and fire extinguisher wasn't serviced, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
06/20/2024
Plan of Correction
1
2
3
4
Facility will service fire extinguisher, repair smoke alarm in room #3, and clear all fire exits by POC due date of 6/20/2024. An immediate civil penalty of $500 was assessed due to a fire clearance violation.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:
Anthony Perez
TELEPHONE:
(323) 485-4915
LICENSING EVALUATOR NAME:
Michael Hood
TELEPHONE:
(916) 531-7341
LICENSING EVALUATOR SIGNATURE:
DATE:
06/19/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/19/2024
LIC809
(FAS) - (06/04)
Page:
8
of
8