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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005361
Report Date: 09/21/2022
Date Signed: 09/21/2022 12:06:18 PM


Document Has Been Signed on 09/21/2022 12:06 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:
09/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:36 AM
MET WITH:Luzviminda EstrellaTIME COMPLETED:
12:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and granted entry into the facility by Caregiver Luzviminda Estrella and explained the reason for the visit.
At 9:45 AM, LPA toured the facility with Caregivers Luzviminda and Epi Estrella. Facility has 6 residents present during today's visit with 1 on hospice. Facility does not have covid precaution signage outside the facility. Facility screens all visitors to the facility and LPA observed the screening/ sanitizing station in the entrance of the facility. Facility utilizes a visitor sign in sheet and documents temperatures. Facility has covid precaution postings inside facility. LPA observed residents relaxing in the facility. All residents appeared happy and well taken care of. Facility appears clean and sanitary. At 9:55 AM, LPA observed two out of five smoke detectors tested are not working due to missing battery or battery put in incorrectly. Smoke detectors have been removed from the hallway outside bedrooms. All resident rooms had the required elements as well as restrooms stocked with soap/ sanitizer. LPA observed Resident 1 (R1) has two bed rails on the bed, one at the foot and one at the head of bed. At 10:00 AM, LPA observed unsecured cleaning supplies in a common bathroom (photos). First aid kit has all required items. At 10:03 AM, LPA observed unsecured cleaning supplies in an unlocked cupboard in the alcove off the kitchen as well as the restroom adjacent to alcove (photos). LPA toured the outside grounds and observed multiple shaded outside visitation areas. Exit gates are unlocked and self latching. LPA observed the water in backyard pond is dark and murky. LPA toured the kitchen and observed ample food supply. Facility does not have emergency food and water. Residents participate in activities such as music, games, and exercise. Facility has ample supply of PPE and cleaning supplies. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation and quarantine. LPA reviewed select resident files during the visit and all files have updated emergency information. All residents and staff are vaccinated for Covid-19. During the visit, it was revealed that Resident 2 had tested positive for Covid-19 on approximately September 14, 2022 and was not reported to the department.
LPA consulted with Caregiver regarding the importance of staff wearing masks at all times per department requirements. CONTINUED ON LIC 809C DATED 09/21/2022.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2022
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 5


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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, LLC
FACILITY NUMBER: 306005361
VISIT DATE: 09/21/2022
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Based on the observations made during today's visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided as well as appeal rights.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 09/21/2022 12:06 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: SPRINGWELL HAVEN, LLC
FACILITY NUMBER: 306005361

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(a)
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

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. Two out of five smoke detectors tested are inoperable due to battery issues and hallway smoke detectors have been removed. The pond water is dark and murky. This poses an immediate health and safety risk to persons in care.
POC Due Date: 09/22/2022
Plan of Correction
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Licensee to ensure all smoke detectors are operational and forward proof to LPA by POC due date. Additionally, please provide a date scheduled for the cleaning of the backyard pond water.
Type A
Section Cited
CCR
87608(a)(5)(A)
Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions.
A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.
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 in one out of five residents. R1 has two bed rails on the bed, one at the feet and one at the head. This poses an immediate health and safety risk to persons in care.
POC Due Date: 09/22/2022
Plan of Correction
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Licensee to remove the rails at the foot of the bed and forward proof 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: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2022
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 09/21/2022 12:06 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: SPRINGWELL HAVEN, LLC
FACILITY NUMBER: 306005361

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
The following shall be stored inaccessible to residents with dementia:
Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.


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 multiple instances of unsecured cleaning supplies and toxins as noted in LIC 809 (photos).This poses an immediate health and safety risk to persons in care. CIVIL PENALTY ASSESSED.
POC Due Date: 09/22/2022
Plan of Correction
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Licensee to secure all noted items and forward proof to LPA by POC due 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: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5


Document Has Been Signed on 09/21/2022 12:06 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: SPRINGWELL HAVEN, LLC
FACILITY NUMBER: 306005361

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
1569.695(a)(2)
Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to..., the facility shall have a plan and supplies available to provide alternative resources during an outage.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above. Facility does not have emergency water or food. This was advised to facility during the prior annual in 2021.This poses a potential health and safety risk to persons in care.
POC Due Date: 10/05/2022
Plan of Correction
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Licensee to obtain emergency food and water and forward proof to LPA by POC due date.
Type B
Section Cited
CCR
87211(a)(1)(D)
Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:
A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence...
Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above. R2 was diagnosed with Covid-19 around September 14, 2022 and the case was not reported to the department. This poses a potential health and safety risk to persons in care.
POC Due Date: 09/22/2022
Plan of Correction
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Licensee to forward covid script and incident report to the department 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: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2022
LIC809 (FAS) - (06/04)
Page: 5 of 5