198320026-11-15-2023-11-AS-DESA-CXHVTG-20231112154307

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320026
Report Date: 11/12/2023
Date Signed: 11/15/2023 09:29:35 AM

Document Has Been Signed on 11/15/2023 09:29 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 11/14/2023 03:40 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

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	On 11/15/23, LPA España created an amendment to the Annual report created 11/12/23. This report serves as an Amendment to annual report created on 11/12/23. This addendum is written to clarify findings description and does not change the annual report findings recorded on 11/12/2023. Report to be signed by authorized representative. **On 11/12/2023 at 2 pm Licensing Program Analyst (LPA) David España conducted an unannounced Required-1-year annual visit. Upon arrival at the facility, LPA España conducted a risk assessment at the front door. Based on the assessment, the facility is clear of Covid-19 infection (No COVID-19 cases). LPA verified that the facility has an approved mitigation plan report. LPA was granted access and allowed to enter the facility to conduct the inspection.LPA met with Staff #1, and they toured the inside and outside grounds of the facility. The Residential Care Facilities for the Elderly (RCFE) facility is licensed for age range 60 and over, approved for (6) non-ambulatory, of which (4) can be bed-ridden, approved hospice waiver for (4), rooms #1, #2, and #3 are approved for bed ridden. LPA observed five (5) residents and two (2) direct caregivers during the visit. During the tour, LPA did not observe bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. A comfortable temperature was maintained in the facility. There are no security bars or weapons on the premises. Resident bathrooms were checked, sufficient liquid soap and paper towels were observed. Toilets and water faucets worked properly, grab bars were secure, the shower was free of mold/mildew, and a non-skid mat was in place. The water temperature measured at 140.1 degrees Fahrenheit. A comfortable temperature was maintained in the facility. Smoke detectors are interconnected and operational.LPA observed the facility was found to be appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food supplies. The facility has (2) fire extinguishers that were charged, smoke detectors, and carbon monoxide were operable. The facility conducted a Fire/Safety Drill on 7/11/2022.Evaluation Report Continues on LIC 809C

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023

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 11/12/2023 03:43 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: WELLSPRING MANOR SENIOR CARE INC	FACILITY NUMBER: 198320026
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above. LPA's observation- LPA and S#1 observed the hot water: At 2:15 PM, LPA measured the hot water temperature in bathroom #4 at 140.1 F degrees, which is not within Title 22 regs and poses an immediate danger to the health and safety of five (5) out of five (5) residents in care..
	POC Due Date: 11/13/2023
	Plan of Correction
1 2 3 4	The administrator shall monitor and record the hot water temp for three weeks and send the LPA the readings. The administrator shall also send to CCL a written statement that they will monitor the hot water temp. Administrator start testing the hot water and provide photo record of hot water temperature to LPA david.espana@dss.ca.gov.

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: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 11/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/12/2023 03:43 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: WELLSPRING MANOR SENIOR CARE INC	FACILITY NUMBER: 198320026
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(a)

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
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above.LPA met with Staff #1 and reviewed records of S#1, S#2, and S#3 which were missing Health Screening Report/Tuberculosis (TB) Clearance (LIC 503)-facility personnel, 1st Verification of first aid training for staff providing care, LIC9052 etc., which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/24/2023
	Plan of Correction
1 2 3 4	The administrator shall provide updated records for all staff members at the facility by POC date. The administrator shall also send to CCL a written statement that they will have all staff files in order and updated. Administrator will email LPA at david.espana@dss.ca.gov by POC date.

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: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 11/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2023

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: WELLSPRING MANOR SENIOR CARE INC	FACILITY NUMBER: 198320026
	VISIT DATE: 11/12/2023

NARRATIVE

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All mandated inspection control posters were posted. The facility has an approved Mitigation Plan Report on file with CCLD.

There were deficiencies were observed during today's inspection.

LPA and S#1 observed the hot water: At 2:15 PM, LPA measured the hot water temperature in bedroom bathroom #4 at 140.1 F degrees, which is not within Title 22 and poses an immediate danger to the health and safety of five (5) out of five (5) residents in care. LPA and S#1 observed ramps with potential hazards by resident room #3. LPA met with Staff #1 and reviewed records of S#1, S#2, and S#3 which were missing Health Screening Report/Tuberculosis (TB) Clearance (LIC 503)-facility personnel, (1st aid) Verification of first aid training for staff providing care, LIC9052 etc. LPA met with Staff #1 and toured the inside and outside grounds of the facility. LPA and Staff#1 did not observe PUB475 in the main entryway of the facility. LPA met with Staff #1 and did not observe annual fire drill with sign and dated plan as indicated Title 22 regulations.

Advisory Notes - Technical Assistance were issued, please see LIC9102-AN.

Type B deficiencies were issued, please see LIC-809D

Physical Plant/Environmental Safety - Type A: 87303(e)(2) -
Physical Plant/Environmental Safety - 87307(d)(4)
Personnel Records/Staff Training - Type B: 87412(a)
Resident Rights/Information - Technical Assistance: 87468(c)(2)(A)
Disaster Preparedness - Technical Violation: 1569.695(d)

An exit interview was conducted with Staff #1 and a hard copy of the report was furnished.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David Espana	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 11/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2023

LIC809 (FAS) - (06/04)

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