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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005361
Report Date: 10/03/2022
Date Signed: 10/03/2022 12:10:05 PM


Document Has Been Signed on 10/03/2022 12:10 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:SPRINGWELL HAVEN, LLCFACILITY NUMBER:
306005361
ADMINISTRATOR:RAMIL DE LOS SANTOSFACILITY TYPE:
740
ADDRESS:2424 FRANCISCO DRIVETELEPHONE:
(949) 524-3484
CITY:NEWPORT BEACHSTATE: CAZIP CODE:
92660
CAPACITY:6CENSUS: 6DATE:
10/03/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Michelle BashaTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced plan of correction visit to follow up on citations issued on 09/21/2022. LPA was greeted and granted entry into the facility by Caregiver Michelle Basha and explained the reason for the visit. LPA consulted with Licensee Ramil De Los Santos via telephone.

At 11:25 AM, LPA toured the facility and observed the following:

*Deficiency cited under Title 22 Regulation 87303(a) pertaining to Maintenance and Operation has been cleared. LPA observed smoke detectors are operational during today's visit as well as a drained fountain in the backyard. Licensee has complied with the terms of the POC.

*Deficiency cited under Health and Safety code 1569.695(a)(2) pertaining to Emergency Disaster Supplies has been cleared. LPA observed ample emergency food and water. Licensee has complied with the POC.

*Deficiency cited under Title 22 Regulation 87211(a)(1)(D) pertaining to Reporting Requirements has been cleared. Licensee provided incident report to the department. Licensee has complied with the POC.

*Deficiency cited under Title 22 Regulation 87705(f)(2) pertaining to Care of Persons with Dementia has been cleared. Licensee secured noted items. Licensee has complied with the POC.

*Deficiency cited under Title 22 Regulation 87608(a)(5)(A) pertaining to Postural Supports has been cleared. Licensee complied with the POC.
Licensee has been advised to maintain all items in compliance.

Exit interview conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2022
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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