342700350-8-27-2025-59-AS-LCRR-DLEQ4E-20250911115014

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700350
Report Date: 08/27/2025
Date Signed: 08/27/2025 04:23:51 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/20/2025 and conducted by Evaluator Michael Hood

COMPLAINT CONTROL NUMBER: 59-AS-20250520090643

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:	08/27/2025
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Doris Espinoza, Administrator		TIME COMPLETED:	04:25 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

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

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

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

Estimated Days of Completion:

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 2

Control Number 59-AS-20250520090643

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 08/27/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

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.

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 2