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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347001619
Report Date: 12/12/2024
Date Signed: 12/12/2024 10:55:28 AM

Document Has Been Signed on 12/12/2024 10:55 AM - 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:GLEN CREEK VILLA II-RES. CARE FAC. FOR THE ELDERLYFACILITY NUMBER:
347001619
ADMINISTRATOR/
DIRECTOR:		OSANU, NICOLETAFACILITY TYPE:
740
ADDRESS:8510 ELM AVENUETELEPHONE:
(916) 988-8285
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
12/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:35 AM
MET WITH:Administrator, Nicoleta OsanuTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
NARRATIVE
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Licensing Program Analyst (LPA) Talwinder Bains arrived unannounced on 12/12/24 to conduct the annual inspection. LPA met with administrator, Nicoleta Osanu who assisted LPA during today's inspection.
During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA reviewed residents (2) and staff files (1). Facility was clean. All required postings were observed. LPA reviewed medications of 2 residents comparing with physician orders.

LPA and Administrator toured the facility together to ensure the health and safety of residents in care. The areas toured included residents rooms, bathrooms, kitchen, common areas and outside area. All exits were unobstructed. The administrator's certificate is current. There is a gate for emergency access. LPA checked the kitchen area for the ability to prepare and store food. Knives and Sharp objects found to be locked . LPA observed cleaning products and other toxins to be locked away. LPA observed the area used for medication to be locked and inaccessible to residents. LPA observed smoke detectors and carbon monoxide detector at the care home are operational. Fire extinguisher is ready for emergency use .Inside temperature was observed to be 76 degree F.

LPA requested a copy of the LIC500, LIC610E and current liability insurance to be sent to the Department by 12/31/24.

Deficiencies were observed and cited per Title 22, CCR Regulations as listed on LIC 809-D. Civil penalties shall be assessed if facility does not comply with POC requirements which were issued today.

Exit interview conducted. Copy of this report and appeal rights were provided.
Laura MunozTELEPHONE: (916) 263-4743
Talwinder BainsTELEPHONE: (916) 263-4700
DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2024
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 12/12/2024 10:55 AM - 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: GLEN CREEK VILLA II-RES. CARE FAC. FOR THE ELDERLY
FACILITY NUMBER: 347001619

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/12/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and staff's interview, it has been found out that facility does not have current medications list for residents, R1,R2 and 2 prescribed medications (Losartan -25 mg and Melatonin 3mg) were not present for R2 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/13/2024
Plan of Correction
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Administrator shall send a letter of understanding of this Regulation and shall conduct all staff training regarding Medication Management and shall proof to Department by POC date-12/13/24. Facility will ensure to have current medication list for all residents in thier records.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Laura MunozTELEPHONE: (916) 263-4743
Talwinder BainsTELEPHONE: (916) 263-4700

DATE: 12/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2024

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/12/2024 10:55 AM - 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: GLEN CREEK VILLA II-RES. CARE FAC. FOR THE ELDERLY
FACILITY NUMBER: 347001619

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/12/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
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:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and staff's interview, it has been found out that staff, S1's First aid/CPR certificate has been Expired and No Annual Training were done for S1 as required, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/10/2025
Plan of Correction
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Administrator shall ensure First Aid/CPR and Annual Training will be completed for staff ,S1 and for All Staff as Required and shall send proof to Department by POC date- 01/10/25.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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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.
Laura MunozTELEPHONE: (916) 263-4743
Talwinder BainsTELEPHONE: (916) 263-4700

DATE: 12/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2024

LIC809 (FAS) - (06/04)
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