198603040-6-22-2023-28-AS-CWOG-CT2VHP-20230622162727

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603040
Report Date: 06/22/2023
Date Signed: 06/22/2023 05:25:38 PM

Document Has Been Signed on 06/22/2023 05:25 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

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: 36	DATE:	06/22/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Linda Fan		TIME COMPLETED:	04:45 PM

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	Licensing Program Analysts (LPA) Christine Wong conducted the required annual inspection. LPA arrived unannounced and met with caregiver Kevin Qin. Assistant administrator Anna Dong assisted with the visit and Administrator, Linda Fan , also arrived to assist the visit at around 11:00am. The purpose for the visit was explained. The facility is licensed for residents age range 60 and over. Approved for 29 non-ambulatory and 14 bedridden, Hospice Waiver for 10. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following 12 domains: 1. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. COVID-19 screening is still in place. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. 2. Operational Requirements: The facility has a dementia care plan to accept or retain residents with dementia. Currently they have 6 hospice residents reside in the facility. The facility has the sufficient amount for liability insurance covering injury to residents and guests. 3. Physical Plant and Environmental Safety: The facility is a two story building, on the first floor, it includes: Reception area, common area (Read newspaper area and exercise area), Administrator office, Dining Area, Kitchen, linen supply room, cleaning supplies room, ten (10) residents bedrooms, laundry room, food storage room and two unisex public bathrooms. On the second floor, it includes seventeen (17) residents bedrooms, 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. On today's annual, LPA inspected five (5) residents bedrooms which include Room#101, #126, #128, #206 and #227. (See LIC809C for continuation)

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/22/2023

NARRATIVE

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Each resident room has their own bathroom. Room#101 and #206 has two beds, two drawers, chairs, required beddings and sufficient lighting and closet space. Room#126, #128 and #227 has one bed, one chair, one drawer, required bedding and sufficient closet space and lighting. The resident bathrooms are clean, sanitary and in an operable condition. All resident bathrooms have grab bar and non skid mat/floor. Each resident room and bathroom have the signal system and they are working properly. The hot water temperature in Room#101 and #206 were tested between 100.2 and 100.7 degrees F.

4. Staffing: There is sufficient staffing at the facility. Staff does not have CPR and First Aid training except the administrator.

5. Personnel Record and Training: The facility administrator is Linda Fan and her administrator certificate will be expired on 11/15/2023 and she has sufficient training hours in file. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. The caregiver/direct care staff do not have required training hours including medication management and initial training.

6. Resident Records and Incident Reports: Resident files are maintained at the facility and have the following documents in their files - Admission Agreements, Identification & Emergency Information, Physician's Report, Pre-admission appraisal, and Resident rights. For Resident#1 and #2 admission agreement and they are not using the Font size 12 and the admission agreement is double sized.

7. Resident Right-Information: The Complaint poster, Local Ombudsman, and Residents personal rights are posted are between the reception area and entrance area.

8.Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical capability.

9.Food Service: The facility has sufficient food supply for 2 days perishable and 7 days non-perishable food supply. The food are properly stored in the refrigerator.

10. Incidental Medical and Dental: The resident's medication is centrally stored and locked in the administrator office. LPA reviewed five (5) residents medication and they all seemed updated and accurate, which contained 30-day supply of medication.
(See LIC 809C for continuation)

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SPRINGVILLE	FACILITY NUMBER: 198603040
	VISIT DATE: 06/22/2023

NARRATIVE

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11.Disaster Preparedness: The facility has an updated Emergency Disaster Plan dated on 6/22/23
The facility staff does not have annual emergency and disaster training. The facility does have two appropriate alternate shelter locations.

12.Resident with Special Health Needs: Currently there's no resident under Home Health Services. Six (6) residents are on hospice. No resident is on postural support and no residents have prohibited health condition. Half and full bed rails for mobility assistance were observed in resident rooms. Individual Service Plans and Appraisals are on file.

Per California Code of Regulations, Title 22, deficiencies were cited.

Exit interview was conducted with Administrator Linda Fan. A copy of the report and appeal rights were issued.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/22/2023 05:25 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
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: 06/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.618(c)(3)

Other Provisions

(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, LPA observed all the staff do not have first aid and CPR in file except Administrator which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/06/2023
	Plan of Correction
1 2 3 4	The administrator send all the staff first aid certificate and CPR to LPA by POC due date.

Type B

Section Cited

HSC

1569.696(a)

Other Provisions

(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on the record review, LPA did not observe any training record for staff in file which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/06/2023
	Plan of Correction
1 2 3 4	The administrator will updated the staff training record and send it 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.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/22/2023 05:25 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
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: 06/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87507(a)(1)(A)

Admission Agreements

(a) The licensee shall complete an individual written admission agreement, as defined in Section 87101(a), with each resident or the resident's representative, if any. (1) The text of the admission agreement, including any attachments and modifications, shall be: (A) Printed in black type of not less than 12-point type size, on plain white paper. The print shall appear on one side of the paper only. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, LPA observed Resident#1 and #2 admission agreemnt was printed less than 12 point type size and on double side of the paper which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/06/2023
	Plan of Correction
1 2 3 4	The administrator will update the resident#1 and #2 admission agreement and send it to LPA by POC due date.

Type B

Section Cited

HSC

1569.695(b)

Other Provisions

(b) A facility shall provide training on the plan to each staff member upon hire and annually thereafter. The training shall include staff responsibilities during an emergency or disaster. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on the record review, LPA did not observe staff has any training on emergency and disaster which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/06/2023
	Plan of Correction
1 2 3 4	The administrator will retain the staff on Emergency and Disaster and send the training log 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.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/22/2023 05:25 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
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: 06/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, LPA observed the facility does not have any documentation about facility conduct a drll at least quarterly for each shift which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/06/2023
	Plan of Correction
1 2 3 4	The facility will send the updated drill(fire and disaster) to LPA by POC due 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: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/22/2023 05:25 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
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: 06/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

87303 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 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on the observation, LPA inspected the Resident room#206 and #101 and their water temperature were tested between 100.2 and 100.7 degrees F which is under Title 22 regulation and posed an immediate risk to residents in care.
	POC Due Date: 06/23/2023
	Plan of Correction
1 2 3 4	The administrator will fix the hot water temperature immediately and send the 7 days hot water temperautre log to LPA by POC due date 6/29/23

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: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

LIC809 (FAS) - (06/04)

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