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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603040
Report Date: 09/28/2023
Date Signed: 09/28/2023 09:56:01 AM

Substantiated


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
04/05/2021 and conducted by Evaluator Christine Wong
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210405152422
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: 31DATE:
09/28/2023
UNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Kevin QinTIME COMPLETED:
10:15 AM
ALLEGATION(S):
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Facility retained resident with a prohibited health condition
Resident received a pressure injury while in care
Staff did not notify authorized representative of residents change in condition
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Wong conducted a “Subsequent” visit to ascertain additional information regarding the above-mentioned allegations and for the purpose of rendering the findings. LPA met with Staff #1 Kevin Qin who allowed entry into the facility and assisted with the visit.

The investigation consisted of the following: On 4/6/2021, LPA Sicairos conducted a virtual tour of the facility with the assistance of the Administrator which included the common areas and a random sample of resident rooms. LPA did not observe any immediate health and/or safety concerns. LPA also interviewed the Administrator. LPA requested copies of resident & staff rosters and copies of Former Resident #1 (R1's) file including but not limited to Physician's Report, Wound Care Assessment, Home Health Information, and Resident Appraisal. On 6/22/2023, LPA Wong interviewed the administrator and Staff#1 (S1). On 03/15/23, LPA Wong referred the complaint to Community Care Licensing (CCL) Program Clinical Consultant (PCC) for a review of medical records that were obtained. (See LIC 9099C for continuation)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023
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 7
Control Number 28-AS-20210405152422
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: 09/28/2023
NARRATIVE
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The investigation revealed of the following: Allegation#1 “Facility retained resident with a prohibited health condition.” R1 was admitted to the facility on 12/28/20 but due to R1’s declining health and began to receive home health services on 1/1/2021. R1 began receiving home health services due to R1’s advanced age, decline in mental health, increased weakness and decline in functional status and incontinence. Per review of medical records obtained and the following was determined: On 01/04/21, R1 developed pressure ulcers on both buttocks. On 1/7/21, it was determined that the pressure ulcers on the left and right buttocks were determined to be stage 2. By 02/01/21, R1 had a total of 4 pressure ulcers determined to be stage 3. It was reported the pressure ulcers worsened over time. Although home health contacted the wound doctor to provide evaluation and treatment for R1, the facility continued to retain the resident with a prohibited health condition and failed to submit an exception request to the Licensing Department.

Allegation#2 “Resident received a pressure injury while in care” R1 was admitted to the facility on 12/28/20 and R1’s family doctor ordered a home health service for R1 due to R1 was bedridden, weakness, and limited mobility. R1 was also identified as high-risk requiring emergency care services and hospitalization due to advanced age, decline in health and incontinence with a high risk of breakdown. It is alleged that when R1 was admitted to the facility on 12/28/20, R1 had a red mark on their buttocks area. Facility staff was aware of this. On 1/7/21, R1 was reported to have two pressure ulcers which had developed on left and right buttocks which were determined to be stage two. On 1/28/21, its documented that R1 developed three pressure ulcers. By 2/1/21, R1 had a total of 4 pressure ulcers with two stage 2, one deep tissue injury and one stage 3 pressure ulcers. Additionally, the facility also did not update, develop, and implement a plan of care when home health identified R1 was at risk of developing pressure ulcers.

Allegation #3 “Staff did not notify authorized representative of residents change in condition” R1 was admitted to the facility on 12/28/20 and family took R1 out from the facility on 3/29/21. It was reported that prior to R1 admitted into the facility, R1 did not wear diapers and was not in wheelchair. It is alleged that, R1's family members were not allowed to be visited R1 in person due to COVID and visitors were only able to communicate with the facility through phone calls. According to R1’s family member, the administrator never provided any updates regarding R1’s change in health condition including that R1 had developed pressure ulcers while residing at the facility. R1’s family members stated that they attempted to go to the facility to visit R1 however due to COVID, she was not allowed to see R1 at the facility.

(See LIC 9099C for continuation)

SUPERVISOR'S NAME: David SicairosTELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 28-AS-20210405152422
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: 09/28/2023
NARRATIVE
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R1’s family member also tried calling the administrator many times for follow up on R1’s health condition, but the administrator never communicated any updates regarding R1’s pressure ulcers. R1’s family member indicated that she was unaware of R1’s pressure ulcers until R1's family member took R1 out from the facility on 3/29/21 and a hole was observed on R1’s sacrum. At that time, R1’s pressure ulcers were staged by a doctor to be stage 4. No one in the facility notified R1’s family that R1 had developed these wounds.

Based on LPA interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.



At this time an Enhanced Civil Penalty (ECP) determination is pending in reference to Health and Safety Code 1569.49(e) & (f) and may be assessed at a later date.

Exit interview was conducted and a copy of this report was provided, LIC 9099D, and appeal rights were provided.
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 7
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
04/05/2021 and conducted by Evaluator Christine Wong
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210405152422

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: 31DATE:
09/28/2023
UNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Kevin QinTIME COMPLETED:
10:15 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not seek timely medical care for the resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Wong conducted a “Subsequent” visit to ascertain additional information regarding the above-mentioned allegation and for the purpose of rendering the findings. LPA met with Staff #1 Kevin Qin who allowed entry into the facility and assisted with the visit.

The investigation consisted of the following: On 4/6/2021, LPA Sicairos conducted a virtual tour of the facility with the assistance of the Administrator which included the common areas and a random sample of resident rooms. LPA did not observe any immediate health and/or safety concerns. LPA also interviewed the Administrator. LPA requested copies of resident & staff rosters and copies of Former Resident #1 (R1's) file including but not limited to Physician's Report, Wound Care Assessment, Home Health Information, and Resident Appraisal. On 6/22/2023, LPA Wong interviewed the administrator and Staff#1 (S1). On 03/15/23, LPA Wong referred the complaint to Community Care Licensing (CCL) Program Clinical Consultant (PCC) for a review of medical records that were obtained.
(See LIC 9099C for continuation)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 28-AS-20210405152422
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: 09/28/2023
NARRATIVE
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The investigation revealed the following: Allegation “Staff did not seek timely medical care for the resident” R1 was admitted to the facility on 12/28/20, and R1’s initial Needs and Service Plan indicated that R1 had smelly urine. Facility did consult with R1’s primary care physician who ordered the home health services for R1. Home health ordered physical therapy for evaluation of physician status and rehabilitation. On 2/1/21, R1 developed total of 4 pressure ulcers and reported the pressure ulcers had worsened. Home health ordered the wound doctor for R1 to provide wound evaluation and treatment as needed. Before R1’s family took R1 back home on 3/29/21, R1 was under the care of a wound doctor. Wound doctor follow up on R1’s pressure injuries every 7 days until the last visit on 3/24/21.

Based on record review and 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 allegation is UNSUBSTANTIATED,



Exit interview held and a copy of the report was provided.
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 28-AS-20210405152422
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/29/2023
Section Cited
CCR
87615(a)(1)
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87615 Prohibited Health Conditions (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly:
(1) Stage 3 and 4 pressure injuries.
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The administrator will ensure person who required health services shall not be admitted or retained in a residential care facility. The administrator will submit a plan of correction to ensure facility is meeting the Title 22 regulation by POC due date.
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The requirement was not met as evidenced by record review, R1 had a total of 4 pressure injuries and determined to be stage 3 and R1 was still retained in the facility which posed an immediate risk to residents in care.
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Type B
10/05/2023
Section Cited
CCR
87468.2(a)(4)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities(a)(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:
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Administrator to submit written Plan of Correction to ensure the facility is meeting Title 22 Regulation. Licensee to submit a faxed or mailed copy of POC by due date.
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(4)(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. The requirement was not met as evidenced by record review, when R1 was admitted to facility and facility staff was aware of R1 had a red mark on buttock area and facility did not update and develop a plan of care which posed a potential risk to residents in care.
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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: David SicairosTELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 28-AS-20210405152422
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/05/2023
Section Cited
CCR
87466
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87466 Observation of the Resident
The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.
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Administrator to submit written Plan of Correction to ensure the facility is meeting Title 22 Regulation. Licensee to submit a faxed or mailed copy of POC by due date.
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The requirement was not met as evidenced by LPA's interviews and R1's family reported they never got any updated from facility about the resident's change of condition until the day the family took R1 out from facility.
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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: David SicairosTELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023
LIC9099 (FAS) - (06/04)
Page: 7 of 7