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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800433
Report Date: 12/28/2021
Date Signed: 12/28/2021 01:14:39 PM

Document Has Been Signed on 12/28/2021 01:14 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:WELLSPRING CENTERFACILITY NUMBER:
361800433
ADMINISTRATOR:LAWRENCE LAWLERFACILITY TYPE:
772
ADDRESS:15217 SAN BERNARDINO AVENUETELEPHONE:
(951) 643-2150
CITY:FONTANASTATE: CAZIP CODE:
92355
CAPACITY: 16CENSUS: 13DATE:
12/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:52 AM
MET WITH:Larry LawlerTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Anna Bueno made an unannounced visit to the facility for the purpose of conducting a required annual inspection, with an emphasis on infection control. LPA met with Larry Lalwer, administrator, and RN supervisor, Rosalind Victor.Single entry point to the main lobby has a sign-in policy for universal entry screening.

During the inspection, LPA Bueno conducted a brief tour of the facility and made observations pertaining to the facility's infection control measures. LPA observed that the facility had several COVID-19 related postings throughout the facility. The facility was also equipped with sufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions, and a 30+ day supply of Personal Protective Equipment (PPE). LPA also observed all staff members were properly fitted with face coverings. confirmed that staff are subject to routine Covid-19 testing.

This facility has a plan in place which follows Community Care Licensing Division guidelines for COVID-19 testing, isolating/quarantining clients, and properly caring for clients with COVID-19 positive results and/or exposures. The facility also has a plan in place to monitor clients regularly for any changes in condition and to subsequently notify the responsible parties and medical personnel in the event the client presents with any COVID-19 symptoms.

LPA Bueno observed no health and safety concerns at the time of visit. Based on observations made during today’s inspection, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted where a copy of this report was discussed and provided to administrator Lawler at the conclusion of the inspection.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 12/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/28/2021
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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