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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603040
Report Date: 06/21/2024
Date Signed: 06/21/2024 04:12:50 PM

Document Has Been Signed on 06/21/2024 04:12 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:SPRINGVILLEFACILITY NUMBER:
198603040
ADMINISTRATOR/
DIRECTOR:		FAN, LINDA LFACILITY TYPE:
740
ADDRESS:12755 TORCH STTELEPHONE:
(626) 337-7288
CITY:BALDWIN PARKSTATE: CAZIP CODE:
91706
CAPACITY: 43CENSUS: 32DATE:
06/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Linda FanTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analysts (LPA) Nune Margaryan conducted an unannounced annual visit using the Care Tool. LPA met with Administrator Linda Fan who assisted with visit. LPA explained the reason for the visit. The facility is licensed for residents age range 60 and over. Approved for 29 non-ambulatory residents of which 14 may be bedridden. Facility approved Hospice waiver for 10. There are currently 8 residents on hospice. The facility is a two story building. LPA and Administrator toured the facility which included: random selection of resident bedrooms on both floors, Reception area, common area / activity exercise area, Administrator office / Medication area, laundry room, dining area, kitchen, linen supply room, cleaning supplies room, two public bathrooms, rest area (TV and computer room), public bathroom but currently used it as storage. The facility also has a large back patio area. The passageways, walkways and patios are free from obstructions. The backyard patio area is well maintained and there are no pools or large bodies of water. The common areas are clean and have the required furniture. The resident bathrooms have the required grabs bars and non-skid mat. The water temperature was tested in a random selection of resident bathrooms and was measured within Title 22 Regulation guidelines. Resident bedrooms have the required furniture such as bed frames, dressers, lamps, and chairs. Bedrooms also have sufficient closet space. Resident beds have the required linen, and the linen is in good condition. At the time of inspection, LPA observed medication in the room #202, on bedside table. LPA observed that facility does not have "No smoking oxygen in use" signs posted on the residents’ rooms who are in hospice and use oxygen. Smoke/Carbon monoxide detectors observed throughout the facility and were operational. There are several fire extinguishers located throughout the facility and observed fully charged. Kitchen appliances are clean and were operating at the time of the visit.

Continue 809C

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE: DATE: 06/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/21/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
Document Has Been Signed on 06/21/2024 04:12 PM - It Cannot Be Edited


Created By: Nune Margaryan On 06/21/2024 at 02:24 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SPRINGVILLE
FACILITY NUMBER: 198603040

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. At the time of inspection, LPA observed medication in the room #202, on bedside table which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/21/2024
Plan of Correction
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Administrator removed and locked the medicine.
Deficiency cleared at the time of visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Wei Siew Ho
LICENSING EVALUATOR NAME:Nune Margaryan
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 06/21/2024 04:12 PM - It Cannot Be Edited


Created By: Nune Margaryan On 06/21/2024 at 02:24 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SPRINGVILLE
FACILITY NUMBER: 198603040

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(26)
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:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed that there's not enough food supply for 7 days non-perishable, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/21/2024
Plan of Correction
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 Grocery shopping was done at the time of visit. The administrator will ensure the supplies of non-perishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.
Deficiency cleared at the time of visit.
Type B
Section Cited
CCR
87618(b)(3)(B)
Oxygen Administration - Gas and Liquid
(3) Ensuring that the use of oxygen equipment meets the following requirements: (B) “No Smoking-Oxygen in Use” signs shall be posted in the appropriate areas.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed that facility does not have "No smoking oxygen in use" signs posted on the residents’ rooms who are in hospice and use oxygen, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/21/2024
Plan of Correction
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"No smoking oxygen in use" signs were printed and posted throughout the facility, outside of residents rooms.
Deficiency cleared at the time of visit.

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:Wei Siew Ho
LICENSING EVALUATOR NAME:Nune Margaryan
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2024


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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SPRINGVILLE
FACILITY NUMBER: 198603040
VISIT DATE: 06/21/2024
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Sharps are locked in the kitchen and are inaccessible to residents. Food supply adequate stored in the kitchen, storage room and consists of the following: 2 days perishable but there's not enough food supply for 7 days non-perishable. Cleaning supplies and toxins were observed in the laundry room and supply room locked and inaccessible to residents. LPA reviewed 3 resident records to confirm emergency contact is updated, physician's reports are on file, and admission agreements are complete. Two staff records were reviewed to confirm health screenings, training, and fingerprint clearances. LPA reviewed 3 residents' medications. Medications are documented properly and given as prescribed. First Aid kit was fully stocked with current manual.


Per California Code of Regulations, Title 22, the deficiencies observed are documented on the attached 809D.

Exit interview held. A copy of the report and appeal rights were provided to Administrator

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2024
LIC809 (FAS) - (06/04)
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