198603040-10-26-2023-28-AS-RORN-CX5LMD-20231031085234

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603040
Report Date: 10/26/2023
Date Signed: 10/26/2023 01:54:46 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/27/2023 and conducted by Evaluator Luis Mora

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230627145047

FACILITY NAME:	SPRINGVILLE		FACILITY NUMBER:	198603040
ADMINISTRATOR:	FAN, LINDA L		FACILITY TYPE:	740
ADDRESS:	12755 TORCH ST		TELEPHONE:	(626) 337-7288
CITY:	BALDWIN PARK	STATE: CA	ZIP CODE:	91706
CAPACITY:	43	CENSUS: 32	DATE:	10/26/2023
		UNANNOUNCED	TIME BEGAN:	12:46 PM
MET WITH:	Kevin Qin - Caregiver		TIME COMPLETED:	02:09 PM

ALLEGATION(S):

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Staff prohibited resident from having visitors.
Staff did not treat resident with dignity or respect.
Staff did not keep the facility free from clutter.
Staff retaliated against resident due complaints regarding resident care.

INVESTIGATION FINDINGS:

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*This report will supersede the report dated 07/06/23 to correct specific information on the report*

Licensing Program Analyst (LPA) Luis Mora conducted an unannounced initial complaint visit to determine the validity of the above-mentioned allegations. LPA met Linda Fan (Administrator) and explained the reason for the visit.

The investigation consisted of the following: LPA Mora obtained copies of the resident and staff rosters, interviewed Administrator, Staff 1 - Staff 2 (S1 - S2), Resident 1 - Resident 7 (R1 - R7), and 4 residents' responsible parties, and toured the facility.

The investigation revealed the following: regarding the allegation "staff prohibited resident from having visitors", it is alleged that on 2/20/2023, a family member of a resident made an appointment with the facility and showed up with home health nurse and were denied entry to the facility. Administrator and staff denied the allegation. (Continued to LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023

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 3

Control Number 28-AS-20230627145047

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SPRINGVILLE	FACILITY NUMBER: 198603040
	VISIT DATE: 10/26/2023

NARRATIVE

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They stated that this occurred during dinner time and all staff were in the dining room serving the residents. The staff told the family member via phone to wait a bit until they were done so they can go open the outside gate for them. However, the family member call the police right away because they were not provided entry to the facility right away. Residents interviewed could not corroborate with the allegation. Residents' responsible parties interviewed could not corroborate with the allegation and stated they have never had any visitation issues with this facility.

The investigation revealed the following: regarding the allegation "staff did not treat resident with dignity or respect", it is alleged that a resident is being discriminated against based on language dialect and receives unfair treatment. Administrator and staff denied the allegation. Residents interviewed could not corroborate the allegation. Residents' responsible parties interviewed could not corroborate with the allegation and stated that during their visits they have not observed staff mistreating or discriminating against residents.

The investigation revealed the following: regarding the allegation "staff did not keep the facility free from clutter", it is alleged that there was clutter obstructing the stairwells. Administrator and staff denied the allegation. Staff 1 (S1) confirmed that pieces of furniture were placed there but it was not obstructing the stairway. They were replacing old furniture with new furniture. The old furniture was removed from that spot by end of the day. A picture was attached to this complaint and based on the picture the clutter is not obstructing the stairwell or hallway. It is in an isolated area near the stairway. It is unknown how long the clutter was there. Residents interviewed could not corroborate the allegation. Residents' responsible parties interviewed could not corroborate with the allegation and stated that during their visits they have not observed any clutter and the facility is clean. During today's visit, the LPA did not observed any clutter in the facility and facility was clean.

The investigation revealed the following: regarding the allegation "staff retaliated against resident due complaints regarding resident care", it is alleged that a resident's November 2022 eviction notice and limitations on visitation are believed to be retaliatory actions from the facility. Administrator and staff denied the allegation and stated visitation rules applied equally to all visitors. Administrator stated there is no eviction notice issued in November 2022 and that it was a recommendation to the resident's family that the resident might need a higher level of care due to the resident's violent behavior towards staff and other residents. Review of resident's records the only eviction notice found was issued on 01/09/2023 due to non-payment and resident needing higher level of care. Residents interviewed could not corroborate the allegation. Residents' responsible parties interviewed could not corroborate with the allegation.
(Continue to LIC 9099-C)

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20230627145047

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SPRINGVILLE	FACILITY NUMBER: 198603040
	VISIT DATE: 10/26/2023

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	Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview held and a copy of the report was provided

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023

LIC9099 (FAS) - (06/04)

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