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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603607
Report Date: 10/17/2023
Date Signed: 10/17/2023 04:04:13 PM

Document Has Been Signed on 10/17/2023 04:04 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:SPRINGFIELD MANORFACILITY NUMBER:
198603607
ADMINISTRATOR:BAIG, SHAHBAZFACILITY TYPE:
735
ADDRESS:2526 NEW AVENUETELEPHONE:
(818) 846-4469
CITY:ROSEMEADSTATE: CAZIP CODE:
91770
CAPACITY: 32CENSUS: 31DATE:
10/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:17 AM
MET WITH:Shabaz Baig, AdministratorTIME COMPLETED:
04:12 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alberto Lopez made an unannounced annual inspection visit. LPA met with Jeam Tan Assistant Administrator and Administrator Shahbaz Baig who assisted with the visit. LPA explained the purpose of today's visit.

This is a one-story Adult Residential Facility (ARF) facility consisting of 16 shared client bedrooms, 9 bathrooms, kitchen, dining room, activities room, laundry room, locked medication cabinet in kitchen, staff office and outdoor shaded area. This facility is licensed for a capacity of 32 clients and today's census was 31.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting clients’ medications. Staff are still cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies. An Infection Control Plan at the facility.


Physical Plant & Environment Safety: The facility is free of debris/hazards. There are no security bars or weapons on the premises. The hot water temperature was tested, and temperature measured between 126.3 -143.7 degrees F which is not within required range of 105.0 -120.0 F. All storage areas for cleaning solutions, toxins, knives, and hazardous items are inaccessible to clients. The last Fire/Emergency Drill was 03/09/23. Smoke detectors and carbon monoxide detectors are operable and in compliance. The fire extinguishers were observed and recently inspected.

Operational Requirements: Facility is complying.

Staffing: There appears to be sufficient staffing in the facility. CPR/First aid certificates are on file. Administrator Assistant Administrator Certificate expires on 02/08/2025. Last fire drill was on 03/09/23

Personnel Records-Training: Staff has criminal record clearance. Staff files are maintained at the facility. Staff have current CPR/first aid training and documentation of ongoing training.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2023
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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Document Has Been Signed on 10/17/2023 04:04 PM - It Cannot Be Edited


Created By: Alberto Lopez On 10/17/2023 at 03:43 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: SPRINGFIELD MANOR
FACILITY NUMBER: 198603607

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

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. Water measured 126.3 to 143,7 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/18/2023
Plan of Correction
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Administrator will adjust water and send proof to LPA by POC date.
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:Lisa Hicks
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/17/2023 04:04 PM - It Cannot Be Edited


Created By: Alberto Lopez On 10/17/2023 at 03:43 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: SPRINGFIELD MANOR
FACILITY NUMBER: 198603607

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the licensee did not comply with the section cited above. One shower was in disrepair and leaking which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/24/2023
Plan of Correction
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Administrator will repair shower and send proof of correction to LPA by POC date.
Type B
Section Cited
CCR
80087(a)(1)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (1) The licensee shall take measures to keep the facility free of flies and other insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above. Ants were observed in the kitchen area which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/20/2023
Plan of Correction
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Administrator will address the ant issue by POC date and send proof to LPA.
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:Lisa Hicks
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2023


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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: SPRINGFIELD MANOR
FACILITY NUMBER: 198603607
VISIT DATE: 10/17/2023
NARRATIVE
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Client Rights-Information: Client personal rights poster is posted in the facility. Internet access is available for clients.
Client Records-Incident Reports: Client files are kept in a secure location within the facility and have the following documents in their files - Admission Agreements, Identification & Emergency Information, Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan. The updates were not dated.
Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.
Health Related Services: Staff designated to administer medication do have the proper annual training on file. Medication is properly labeled and are centrally stored in a locked medication cabinet located in the kitchen. All medications are properly labeled and in their original containers. During the visit today, LPA reviewed all 5 clients' medications, all medication is administered according to doctor’s orders. PRN Authorization letters were missing for two clients.
Incidental Medical Services: Facility is complying and has documentation on file.
Disaster Preparedness: The facility has an Emergency Disaster Plan at facility but needs updating.
Emergency Intervention: Clients at this facility do not have restraints nor do they require the use de-escalation techniques.

Deficiencies cited during today's visit. Technical advisories were provided.

An exit interview was conducted and a copy of this report and appeal rights were provided to Administrator.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023
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