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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800138
Report Date: 11/01/2023
Date Signed: 11/01/2023 03:36:00 PM

Document Has Been Signed on 11/01/2023 03:36 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:WELL SPRING HOMES INCFACILITY NUMBER:
361800138
ADMINISTRATOR:LANDICHO, ROBERTFACILITY TYPE:
735
ADDRESS:941 E HOME STTELEPHONE:
(626) 241-3726
CITY:RIALTOSTATE: CAZIP CODE:
92376
CAPACITY: 4CENSUS: 1DATE:
11/01/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Martin Melicado, Direct Care StaffTIME COMPLETED:
03:45 PM
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Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Well Spring Home, Inc. Adult Residential Facility unannounced to conduct an Annual Inspection. LPA was greeted by Martin Melicado, Direct Care Staff. LPA introduced self and stated purpose of the visit. Mr. Melicado contacted the Administrator, Robert Landicho, LPA spoke with Mr. Landicho over the phone; LPA introduced self and stated purpose of the visit.

A tour of the facility was conducted inside and out of physical plant, the following was observed:
Facility: The facility is approved to provide services for four ambulatory adults; ages 18 to 59.
Mr. Maelicado reported that there are 4 residents in care. Three resident were home at time of visit. LPA observed that the facility is operating in the capacity and conditions approved by Community Care Licensing. The facility also maintains vendorship with Inland Regional Center at Level 4I.

Physical Plant: The temperature throughout facility was comfortable. The facility includes 5 bedrooms, (4 resident rooms & 1 staff room.) two bathrooms, kitchen, dining room, living room, backyard and attached garage. Each resident room included all regulated furniture such as: Mattress & fitting sheets, sufficient lighting and storage. Each of the bathrooms contained sufficient amounts of hand soap, paper towels, trash bins and operational appliances. LPA also observed the bathtubs included a non-slip grip mat. The hallways were illuminated by night lights. The facility is equipped with operational smoke alarms and carbon monoxide detectors. LPA also observed a fully charged fire extinguisher. Last inspected February 2023. Program Supervisor reports, that the facility conducts fire and disaster drills every month. Last Fire Drill was on 10/21/23. Last Earthquake Drill 10/24/23. Additionally, the facility conducts house meetings monthly.
Pathways throughout the facility and in the backyard were free of obstructions. LPA observed the washer and dryer in the attached garage. Both in operable conditions. LPA observed that chemicals and toxins secure in the garage sliding door cabinets. LPA observed posters of the facility license, resident rights, resident roster, emergency evacuation plans and the Long Term Care Ombudsman posted in common areas.
Please see LIC809-C
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2023
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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: WELL SPRING HOMES INC
FACILITY NUMBER: 361800138
VISIT DATE: 11/01/2023
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Food Service: LPA observed the facility kitchen which contained operational appliances. The refrigerator was well stocked with adequate amounts of food items for the residents. LPA observed bread, water, milk, cheese and eggs. Staff revealed the facility pantry, where LPA observed cans of beans, soup, gravy and vegetables - all in good standing. LPA observed a weekly food menu posted on the refrigerator. The menu offered a variety of meals such as oatmeal, pancakes, sandwiches and soup for residents in care, Sharp objects were observed in a secure drawer. LPA measured the water temperatures in the facility kitchen; and found that the water temperature ranged between 105 to 110 degrees. The facility also maintains adequate emergency supplies of food and water for the resident in case of a disaster or emergency; along with first aid kits.
Care & Supervision: Facility has sufficient care staff. Three staff members present during visit. Additionally three staff members reside on facility grounds. The Administrator arrived later during visit to provide LPA with the staff files as they are centrally stored.
Record Review and Resident/Staff Files: LPA reviewed 4 staff files. Each of the 4 staff records/file were complete with current with training and criminal background/fingerprint clearances; per regulation. LPA reviewed 2 resident files. LPA found that resident each was complete with current Needs and Services Plans, Physician Reports, and Individual Programs Plans, Admission Agreements and emergency contact information; as regulated.

Based on observations, record reviews and interviews, no deficiencies were observed during the visit. An exit interview was conducted where this report was reviewed, discussed and provided to Administrator, Robert Landicho.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2023
LIC809 (FAS) - (06/04)
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