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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800138
Report Date: 11/26/2024
Date Signed: 11/26/2024 03:59:48 PM

Document Has Been Signed on 11/26/2024 03:59 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:WELL SPRING HOMES INCFACILITY NUMBER:
361800138
ADMINISTRATOR/
DIRECTOR:		LANDICHO, ROBERTFACILITY TYPE:
735
ADDRESS:941 E HOME STTELEPHONE:
(626) 241-3726
CITY:RIALTOSTATE: CAZIP CODE:
92376
CAPACITY: 4CENSUS: 0DATE:
11/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:03 PM
MET WITH:Robert Landicho, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:10 PM
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Licensing Program Analyst, LaVette Farlow, (LPA) arrived at the Well Spring Home, Inc. Adult Residential Facility unannounced to conduct an Annual Inspection. Upon arrival LPA rang door bell and no one answered. LPA waited 5 minutes and proceeded to call the number listed on the profile and staff arrived. 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, and Administrator Robert stated he would be on his way. LPA met with Administrator Robert Landicho and 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. Melicado reported that there are four (4) resident in care and all four (4) are currently at the Day Program. 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 March 2024. Program Supervisor reports, that the facility conducts fire and disaster drills every month. Last Fire Drill was on 10/22/24. Last Earthquake Drill 10/22/24. 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: Lavette Farlow
LICENSING EVALUATOR SIGNATURE: DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/26/2024
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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: WELL SPRING HOMES INC
FACILITY NUMBER: 361800138
VISIT DATE: 11/26/2024
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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/bathroom; and found that the water temperature ranged between 108.6 to 119.9 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 to maintain operation of residents in care. Additionally three staff members reside on facility grounds. Staff provided LPA with the staff files as they are centrally stored.

Record Review and Resident/Staff Files: LPA reviewed 3 staff files. Each of the 3 staff records/file were complete with current training and criminal background/fingerprint clearances; per regulation. LPA reviewed 2 resident files. LPA found that resident files were complete with current Needs and Services Plans, Physician Reports, and Individual Programs Plans, Admission Agreements and emergency contact information; as regulated. LPA reviewed facility's P&I records for 2 residents. LPA observed that Administrator Robert does not maintain P&I records on the facility premises, in a locked secured location. Licensee Robert stated the P&I records and funds are maintained at the office. One deficiency cited.

Based on observations, record reviews and interviews, one deficiencies was cited during this visit. An exit interview was conducted where this report LIC809, LIC809C and LIC809D was reviewed, discussed and provided to Administrator, Robert Landicho.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Lavette Farlow
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/26/2024 03:59 PM - It Cannot Be Edited


Created By: Lavette Farlow On 11/26/2024 at 03:17 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: WELL SPRING HOMES INC
FACILITY NUMBER: 361800138

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80026(j)
Safeguards for Cash Resources, Personal Property and Valuables
(j) Cash resources entrusted to the licensee and kept on the facility premises, shall be kept in a locked and secure location.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 4 out of 4 resident P&I records. Licensee does not have a ledger for resident in care. Which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/06/2024
Plan of Correction
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Licensee stated he will provide LPA with proof of cash resources entrusted to the licensee and will keep the monies on the facility premises in a locked and secured location. Licensee states he will provide a statement that he will keep separate envelopes for each client's P&I monies that the facility maintains as verification by 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:Nedra Brown
LICENSING EVALUATOR NAME:Lavette Farlow
LICENSING EVALUATOR SIGNATURE:
DATE: 11/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/26/2024


LIC809 (FAS) - (06/04)
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