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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603040
Report Date: 01/09/2024
Date Signed: 01/09/2024 11:39:26 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
12/23/2022 and conducted by Evaluator Valeria Maldonado
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20221223090814
FACILITY NAME:SPRINGVILLEFACILITY NUMBER:
198603040
ADMINISTRATOR:FAN, LINDA LFACILITY TYPE:
740
ADDRESS:12755 TORCH STTELEPHONE:
(626) 337-7288
CITY:BALDWIN PARKSTATE: CAZIP CODE:
91706
CAPACITY:43CENSUS: 28DATE:
01/09/2024
UNANNOUNCEDTIME BEGAN:
09:51 AM
MET WITH:Linda Fan- AdministratorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Facility is not following the proper protocol for COVID-19.
Facility is not complying with the local health department's guidelines for COVID-19.
Facility is violating residents' personal rights.
Facility is not allowing visitors.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) V. Maldonado made an unannounced subsequent visit to the facility for the purpose of delivering findings in regard to the investigation of the above-mentioned allegations. LPA Maldonado met with Administrator, Linda Fan, and explained the purpose for the visit.

On 12/29/22, LPA Maldonado conducted the initial complaint visit. During the visit, LPA Maldonado obtained a copy of the resident roster and staff roster (with staff contact information, including language preference). LPA Maldonado obtained assistance from LPA Christine Wong, telephonically, to assist with translating, as the majority of staff and residents at the facility speak a different language. LPA's Maldonado and Wong conducted interviews with Staff #1-3 (S1-S3) and Residents #1-5 (R1-R5). LPA also obtained copies of the facesheet and physician's report for R1-R5 and conducted a tour of the physical plant with administrator Linda Fan.
During today's visit, LPA Maldonado delivered findings to the allegations of this complaint.
(Report Continued on LIC9099-C...)
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Valeria Maldonado
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023
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 4
Control Number 28-AS-20221223090814
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SPRINGVILLE
FACILITY NUMBER: 198603040
VISIT DATE: 01/09/2024
NARRATIVE
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The investigation revealed the following:
Regarding allegation- Facility is not following the proper protocol for COVID-19.
It is alleged that the facility is following COVID-19 procedures that are far stricter than any other guidance by requiring residents to isolate for 5 days any time they are out of the community, not allowing visitations in resident rooms, and requiring visitors to take a COVID test upon arrival. On 12/29/22, upon arrival to the facility, LPA Maldonado rang the bell at the gate to request entry and was unable to enter the gated community. LPA was questioned for vaccination status and/or to take a COVID test to be allowed entry by facility staff. LPA explained that the visit was a licensing visit and LPA had inspection authority, regardless. Facility staff then allowed LPA entry through the gate. LPA observed a note posted on the front door of the facility, indicating that only outside visitations were allowed, visitors were to have no physical contact with residents, scheduled visits were required, a negative COVID-19 test was required for entry, face masks were required for both residents and staff at all times, room visits with residents were not allowed, and visitors were not allowed to move about the facility anywhere at any time during said visits. LPA observed a resident in a wheelchair sitting in the lobby area wearing a mask below their chin. Administrator Fan walked up to the resident and without warning, pulled their mask up over their nose and mouth and told the resident to keep it on. At the time of LPA's initial visit, the requirement for requesting a negative COVID-19 test or vaccination status was no longer in place by the Licensing agency. LPA explained this to the Administrator, to which which she stated she still required this to keep residents safe as well as making an appointment prior to visiting. LPA explained that is a violation of resident's personal rights and could not be implemented as a requirement. During interviews with staff, (3) of (3) staff admitted to this allegation stating that they only want to keep residents safe from contracting COVID-19. LPA Maldonado asked Administrator Fan what the quarantine policy was. She admitted that any time a resident went out of the facility, they were required to quarantine/isolate in their room for (5) days to ensure the safety of others, regardless of whether there was possible exposure or they had symptoms. (5) of (5) residents interviewed corroborated the allegations, stating that no room visits are allowed, a 5-day isolation period is required any time they leave, and their visitations are required to be outside.
Regarding allegation: Facility is not complying with the local health department's guidelines for COVID-19. It is alleged that the facility is only allowing resident visitors so long as they make an appointment prior to their visit and that the visit is only conducted outdoors, which is different than what the current visitation guidance was, set forth in the Los Angeles County Department of Public Health Guidance for Community Care Facilities, updated 11/10/2022. After review of the LA County Department of Public Health visitation guidance, it was noted that indoor and outdoor visitation is allowed in green and yellow zones regardless of current outbreak status. (3) of (3) staff interviewed admitted to this facility policy/requirement, stating that they are trying to ensure residents health and safety to COVID-19. (5) of (5) residents interviewed corroborated the allegation stating that they can only receive their visitors outdoors, and by appointment only.
(Report continued on LIC9099-C)
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Valeria Maldonado
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 28-AS-20221223090814
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SPRINGVILLE
FACILITY NUMBER: 198603040
VISIT DATE: 01/09/2024
NARRATIVE
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Regarding allegation: Facility is violating residents' personal rights.
It is alleged that the facility is not allowing visitors without appointments, is requiring residents to isolate for (5) days any time they leave the facility, are enforcing the isolation by restraining residents from leave by placing a stanchion cord across their room door, which is tied/clipped on both sides of the grab bars located outside their door, and not allowing private visits inside residents rooms, which are all violations of residents' personal rights. (3) of (3) staff interviewed admitted to this allegation, stating they are only trying to maintain residents safe from contracting COVID-19. (5) of (5) residents corroborated the allegation stating that while all this is true, they are okay with the requirements of the facility. LPA attempted to explain to both residents and staff that while residents and their families may be okay with this, the facility is violating residents' personal rights, as they are allowed to have visitations in their rooms, are not required to isolate, and cannot enforce the isolation by restraining them with the stanchion cord.
Regarding allegation: Facility is not allowing visitors.
It is alleged that that facility requires that visits must take place outside, that visitors without an appointment will be turned away at the gate, that visitors must test, and that bedridden residents will only be allowed visitation in case of emergency. (3) of (3) staff interviewed admitted to the allegation stating that they are only trying to maintain residents safe from contracting COVID-19. (5) of (5) residents corroborated the allegation stating that all of their visits must be outside, given their visitors made an appointment, otherwise the visit is not allowed.

Based on LPAs observations, interviews conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegations are found to be Substantiated.

Per California Code of Regulations, Title 22, deficiencies will be cited on the LIC9099-D.

An exit interview was conducted and a copy of this report and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Valeria Maldonado
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 28-AS-20221223090814
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SPRINGVILLE
FACILITY NUMBER: 198603040
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
01/16/2024
Section Cited
CCR
87468.1(a)(6)
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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(6)...to not be locked into any room, building, or on facility premises by day or night.
This requirement was not met as evidenced by:
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Administrator to submit a written plan on how they will ensure to not violate resident's personal rights under any circumstances. Written plan to be emailed to LPA by the POC due date.
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Based on observation and interview, the administrator admitted to tying a stanchion red rope accross resident room doors to enforce isolation requirements put forth by the facility, which poses a potential Health, Safety, or Personal Rights risk to persons in care.
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Request Denied
Type B
01/16/2024
Section Cited
CCR
87468.1(a)(11)
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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights
(11)To have their visitors... permitted to visit privately...
This requirement was not met as evidenced by:
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Based on observation and interview, the administrator failed to allow residents their private visits at any given time by requiring them to schedule visits and visits to not be in their rooms if preferred, which poses a potential Health, Safety, or Personal Rights risk to persons in care.
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Administrator will conduct in-service training for all facility staff regarding all resident personal rights. Training material and Sign-In sheet for participants will be emailed to LPA by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Valeria Maldonado
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4