Community Care Licensing

SUPERVISOR'S NAME: Anthony Perez TELEPHONE: (323) 485-4915 LICENSING EVALUATOR NAME: Michael Hood TELEPHONE: (916) 531-7341 LICENSING EVALUATOR SIGNATURE: DATE: 09/10/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/10/2024

Document Has Been Signed on 09/23/2024 03:50 PM - It Cannot Be Edited

FACILITY NAME: SPRING GLEN ELDERLY CARE VILLA	FACILITY NUMBER: 342700350
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/10/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/25/2024 Section Cited HSC 1569.625(b)(1)	1 2 3 4 5 6 7	(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:	1 2 3 4 5 6 7	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 9/25/2024.
	8 9 10 11 12 13 14	Based on LPAs' 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.	8 9 10 11 12 13 14	A civil penalty in the amount of $250 was assessed for repeat violation.
Type B 09/25/2024 Section Cited CCR87555(b)(26)	1 2 3 4 5 6 7	87555 General Food Service Requirements (b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Facility will ensure to have a two (2) day perishable and seven (7) day nonperishable food supply on cite. Licensee will complete a statement of understanding regarding regulation 87555 and submit statement to LPA by POC due date of 9/25/2024.
	8 9 10 11 12 13 14	Based on LPAs' observations, facility did not ensure to have a seven (7) day nonperishable food supply on cite, which poses a potential health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14

SUPERVISOR'S NAME: Anthony Perez TELEPHONE: (323) 485-4915 LICENSING EVALUATOR NAME: Michael Hood TELEPHONE: (916) 531-7341 LICENSING EVALUATOR SIGNATURE: DATE: 09/10/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/10/2024

Document Has Been Signed on 09/23/2024 03:50 PM - It Cannot Be Edited

FACILITY NAME: SPRING GLEN ELDERLY CARE VILLA	FACILITY NUMBER: 342700350
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/10/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/11/2024 Section Cited CCR 87309(a)	1 2 3 4 5 6 7	(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:	1 2 3 4 5 6 7	Facility will conduct an in-service training for staff regarding regulation 87309. Facility will submit date of training and materials to LPA by POC due date of 9/11/2024. A civil penalty in the amount of $250 was assessed for repeat violation.
	8 9 10 11 12 13 14	Based on LPAs' observations, the facility did not ensure that storages for disinfectants, cleaning solutions, and knives were locked and inaccessible to the residents at all times, which poses an immediate health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14
Type A 09/11/2024 Section Cited CCR87465(a)(4)	1 2 3 4 5 6 7	(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Facility will complete a weekly medication audit and document audit for the next month. Facility will submit documentation for weekly audit to LPA each week. A civil penalty in the amount of $250 was assessed for repeat violation.
	8 9 10 11 12 13 14	Based on LPAs' 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.	8 9 10 11 12 13 14

SUPERVISOR'S NAME: Anthony Perez TELEPHONE: (323) 485-4915 LICENSING EVALUATOR NAME: Michael Hood TELEPHONE: (916) 531-7341 LICENSING EVALUATOR SIGNATURE: DATE: 09/10/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/10/2024