Spring Glen Elderly Care Villa

Allegation investigated: Facility's outdoor perimeter fencing is in disrepair, posing a safety risk to residents in care

Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Administrator, Doris Espinoza, to open a complaint investigation into the allegation listed above. During visit, LPA toured the premises. LPA observed a portion of the fence surrounding the property to be in disrepair. LPA observed portion of the fence in disrepair to be inaccessible to residents in care and away from any pathways or emergency exits. Based on LPA's observations, it is determined that disrepair of the fence does not pose a safety risk to the residents in care. LPA issued a deficiency regarding repair of the care home, including backyard fence, in a separate inspection conducted on June 17, 2026. Based on observations, the above allegation is found to be UNFOUNDED. A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. Exit interview was conducted. A copy of the report was provided. Signatures on these forms acknowledges receipt of these documents. Unfoundedthe state’s words, verbatim · CDSS document, Jun 17, 2026 · control 59-AS-20260609142455

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Michael Hood arrived at the care home unannounced on June 17, 2026 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 six (6) 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 117 degrees F. LPA checked the kitchen area for the ability to prepare and store food. Care home has required two (2) day perishable and seven (7) day non-perishable food supply on site. LPA observed the backyard and perimeter of the care home and observed emergency exits to be unobstructed. LPA observed smoke detectors and carbon monoxide detectors to be operational in the care home. First aid kit is maintained and ready for emergency use. LPA checked two (2) residents' medications, six (6) resident files, and three (3) 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, Section 87465 due to medications being accessible to residents in staff bedroom, and Section 87303 due to cleanliness and repair of the care home, including backyard fence in disrepair, debris in backyard, interior floors in disrepair, dishes in kitchen sink, and dish washer in disrepair. Deficiencies are listed on 809-D pages. Exit interview was conducted. A copy of this report and appeal rights were provided. Signatures on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Jun 17, 2026

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPAs) Michael Hood and Marisa Chiarelli arrived at the facility and met with Administrator, Doris Espinoza, to conduct a case management health and safety check. LPAs conducted an inspection of the care home to ensure compliance with Title 22 regulations. There are six (6) bedrooms and two (2) bathrooms for resident use. LPAs observed bedrooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition and properly maintained. LPAs checked the kitchen area for the ability to prepare and store food. Care home has required two (2) day perishable and seven (7) day non-perishable food supply on cite. LPAs observed the backyard and perimeter of the care home to be free of clutter and debris. LPAs observed smoke detectors and carbon monoxide detectors to be operational in the care home. First aid kit is maintained and ready for emergency use. LPAs checked two (2) residents' medications and observed medication to be locked and inaccessible to the residents in care. LPAs reviewed six (6) resident records and three (3) staff records. LPAs observed that all records were complete and staff training was complete. LPAs observed staff on the premises to have a criminal background clearance on file. As a result of today's inspection, no deficiencies are being cited. Exit interview was conducted and a copy of this report was provided. Signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Dec 18, 2025

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Administrator, Doris Espinoza, to conduct a case management health and safety check. 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. LPA checked the kitchen area for the ability to prepare and store food. Care home has required two (2) day perishable and seven (7) day non-perishable food supply on cite. LPA observed the backyard and perimeter of the care home to be free of clutter and debris. LPA observed smoke detectors and carbon monoxide detectors to be operational in the care home. First aid kit is maintained and ready for emergency use. LPA checked two (2) residents' medications and observed medication to be locked and inaccessible to the residents in care. LPA reviewed six (6) resident records and three (3) staff records. LPA observed that all records were complete and staff training was complete. LPA observed staff on the premises to have a criminal background clearance on file. As a result of today's inspection, no deficiencies are being cited. Exit interview was conducted and a copy of this report was provided. Signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Oct 24, 2025

Allegation investigated: Resident sustained unexplained injuries while in care due to neglect or lack of care and supervision

Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Administrator, Doris Espinoza, to deliver findings into the complaint allegation listed above. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: Allegation: Resident sustained unexplained injuries while in care due to neglect or lack of care and supervision ** Report continued on 9099-C ** Unsubstantiated On May 18. 2025, resident (R1) was admitted to the hospital due to complaints of stomach and back pain. While being evaluated by medical staff, it was discovered R1 had “aged” fractures, including an age indeterminate fracture deformity of the humeral neck. Per ER doctor, the injuries could have been caused by a “subacute” (slower onset illness). Doctor had no clear evidence to support R1 was being mistreated, however, doctor found it “inconsistent” that no falls were reported despite R1 sustaining “multiple subacute to chronic compression fractures.” The Department conducted interviews with several staff, who all denied ever witnessing R1 sustaining a fall or being involved in any sort of incident which could have caused injury. Staff reported R1 receives one-on-one (1:1) care and staff are with R1 at all times. R1 tends to walk without the assistance of their walker, so staff will escort R1 around the house. The Department conducted interviews with several residents, including R1 who still lives in the facility. Most residents have dementia, but overall there were no complaints from the residents regarding the staff and care being provided at the facility. The Department interviewed relevant party who oversees R1’s care since August of 2023. Relevant party had no concerns of abuse at the facility. Relevant party was only aware of one (1) fall, which occurred on August 15, 2024 for which R1 received medical attention. Relevant party noted R1 used to have an authorized representative who was neglecting and financially abusing R1 over a few year period. Relevant party believed “aged fractures” could have occurred during the time period in which authorized representative was overseeing R1’s care. During visit conducted on May 22, 2025, LPA Michael Hood and Local Long Term Care Ombudsman met with R1 regarding complaint. R1 stated that they were “pretty fine” and denied having hurt their neck. R1 stated that they haven’t fallen but came close to falling. Based on interviews conducted and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegation is found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means 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 was conducted. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Aug 27, 2025 · control 59-AS-20250520090643

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Administrator, Doris Espinoza, regarding information obtained during inspection conducted on May 22, 2025. During visit, LPA obtained a copy of the facility's surety bond for the Department's record to allow the facility to handle resident cash. Despite surety bond, facility will not handle resident cash and will bill families after additional services provided. LPA also obtained a permit from the county regarding adding an additional bedroom to the care home. Fire inspection has already been requested and facility is in the process of obtaining fire clearance for the room. As a result of today's visit, no deficiencies were cited per Title 22. Exit interview was conducted and a copy of the report provided. Signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Jun 3, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Michael Hood arrived at the facility unannounced on 5/22/25 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 115 degrees F. LPA checked the kitchen area for the ability to prepare and store food. Care home has required two (2) day perishable and seven (7) day non-perishable food supply on cite. LPA observed knives, cleaning products, and other toxins to be locked away and inaccessible to residents. LPA observed the backyard and perimeter of the care home to be free of clutter and debris. LPA observed smoke detectors and carbon monoxide detectors to be operational in the care home. First aid kit is maintained and ready for emergency use. LPA checked two (2) residents' medications and found medication to be locked away and inaccessible to the residents. LPA reviewed five (5) 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 this visit, no deficiencies were cited per California Code of Regulations, Title 22. Exit interview conducted and copy of report given at the conclusion of this visit.the state’s words, verbatim · CDSS document, May 22, 2025

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Administrator, Doris Espinoza, to conduct a case management health and safety check. 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. LPA checked the kitchen area for the ability to prepare and store food. Care home has required two (2) day perishable and seven (7) day non-perishable food supply on cite. LPA observed knives, cleaning products, and other toxins to be locked away and inaccessible to residents. LPA observed the backyard and perimeter of the care home to be free of clutter and debris. LPA observed smoke detectors and carbon monoxide detectors to be operational in the care home. First aid kit is maintained and ready for emergency use. LPA checked two (2) residents' medications and observed medication to be locked and inaccessible to the residents in care. LPA reviewed six (6) resident records and two (2) staff records. LPA observed that all records were complete and staff training was complete. LPA observed staff on the premises to have a criminal background clearance on file. As a result of today's inspection, no deficiencies are being cited. Exit interview was conducted and a copy of this report was provided. Signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Apr 2, 2025

Type of visit: Office

An informal conference was conducted at 9:00 AM on September 30, 2024, with Sacramento North Regional Office via Microsoft Teams. The purpose of this informal conference meeting is to address citations issued during inspections conducted on 6/19/2024 and 9/10/2024. The Administrator was told that this Informal conference is a part of the Administrative Action process and that further noncompliance may result in an elevation to a formal noncompliance conference, which could lead to a referral to the Department's legal division for possible revocation of license. The following Licensing staff were present: Licensing Program Analysts (LPAs) Michael Hood and Cassie Mikkelson, and Licensing Program Manager (LPM) Anthony Perez The following facility representatives were present: Administrator Doris Espinoza, and Licensee Leilani Aragon The following topics were covered during today's meeting: · An overview regarding 6 Type A citations, 9 Type B citations, and 4 civil penalties · Recommendations for pending plan of corrections · Recommended hours for Administrator's presence at the facility. Administrator submitted updated documents prior to meeting showing new hours for Administrator to be at facility. Facility was notified that the Department may increase monitoring at the facility. Technical support was offered to facility representative during meeting. An exit interview was conducted and a copy of this report will be provided to the facility via email. A copy must be signed and returned to the Department.the state’s words, verbatim · CDSS document, Sep 30, 2024

Type of visit: POC

Licensing Program Analysts (LPAs) Michael Hood and Cassie Mikkelson arrived at the facility and met with Administrator, Melissa Szeto, to follow-up on plan of corrections made to the facility during an inspection conducted on 6/19/2024. During today's visit, LPAs conducted a tour of the care home. LPAs observed backyard and perimeter of the care home to be free of clutter and debris. LPAs inspected medication and conducted file reviews for six (6) residents and two (2) staff. LPAs observed residents to have property and valuable records on file. LPAs observed staff at the care home to have CPR and first aid training. LPAs observed staff to have health screenings on file. LPAs observed knives and disinfectants unlocked and accessible to the residents in care in the kitchen area. LPAs observed medications administered not documented with start dates. LPAs observed new staff to have an insufficient amount of initial training documented. LPAs observed an insufficient amount of nonperishable food supply on cite. As a result of today's inspection, deficiencies are being cited pursuant to California Code of Regulations, Title 22, Division 6, Chapter 8. Civil penalties were assessed as a result of today's visit. Deficiencies are listed on 809-D pages. Exit interview was conducted with Administrator. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Sep 10, 2024

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.625(b)(1) · Plan of correction due date: Sep 25, 2024

(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: 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.the state’s words, verbatim · CDSS document, Sep 10, 2024

Plan of correction: 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. A civil penalty in the amount of $250 was assessed for repeat violation.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87555(b)(26) · Plan of correction due date: Sep 25, 2024

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: 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.the state’s words, verbatim · CDSS document, Sep 10, 2024

Plan of correction: 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.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Sep 11, 2024

(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: 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.the state’s words, verbatim · CDSS document, Sep 10, 2024

Plan of correction: 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.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(a)(4) · Plan of correction due date: Sep 11, 2024

(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: 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.the state’s words, verbatim · CDSS document, Sep 10, 2024

Plan of correction: 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.

Type of visit: Required - 1 Year

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 § 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.the state’s words, verbatim · CDSS document, Jun 19, 2024