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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320026
Report Date: 08/11/2021
Date Signed: 09/02/2021 12:16:42 PM

Document Has Been Signed on 09/02/2021 12:16 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, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
FACILITY NAME:WELLSPRING MANOR SENIOR CARE INCFACILITY NUMBER:
198320026
ADMINISTRATOR:BAUTISTA, TERESITAFACILITY TYPE:
740
ADDRESS:2260 W 236TH PLACETELEPHONE:
(310) 418-7938
CITY:TORRANCESTATE: CAZIP CODE:
90501
CAPACITY: 6CENSUS: 5DATE:
08/11/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:12 AM
MET WITH:TERESITA BAUTISTATIME COMPLETED:
04:00 PM
NARRATIVE
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On 8/11/202, Licensing Program Analyst (LPA) Lourdes Montoya conducted an unannounced required annual visit with a primary focus on Infection Control measures using the new CARE Inspection Tools. At around 9:12 am, LPA Montoya called Administrator Teresita Bautista and conducted a risk assessment. Based on the assessment, the facility is clear of Covid-19 infection. LPA verified that the facility has an approved mitigation plan report. LPA met with Administrator Bautista and Staff Joel Morales and they toured the inside and outside grounds of the facility.

The facility is licensed for six (6) non- ambulatory, of which four (4) can be bedridden; approved hospice waiver for four (4) residents. LPA observed five (5) residents and 4 staff including the administrator during the visit.

During the tour, LPA observed the facility’s infection control practices. LPA did not observe a sanitizing station at the facility entrance, temperature checks and daily routine symptoms screening log of staff, residents and visitors; visitors log was observed. PPE supplies are readily available to staff, and an additional 30-day supply of PPE is stored in the garage; sufficient paper, cleaning, and disinfecting supplies were observed. The facility’s designated visitation areas are the resident’s bedroom and the back patio. LPA observed staff, residents, and visitors maintain 6 feet physical distancing, and each person wears a face covering. LPA observed required postings throughout the facility.

A review of vaccination records was conducted; four (4) out of five (5) residents and all five (5) staff have been vaccinated with Covid-19. None of the staff have completed the N-95 fit testing. Per Staff Joel Morales, the facility staff received an Infection Prevention and Control training from the Department of Public Health in January 2021.

Two (2) out of five (5) residents have memory care needs. Potentially dangerous items, including sanitizers, are kept inaccessible to residents with dementia. LPA observed the auditory devices in resident bedroom #2 and the sliding door in the living are not operable.

REPORT CONTINUED IN LIC 809C

SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE: DATE: 08/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/11/2021
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 6
Document Has Been Signed on 09/02/2021 12:16 PM - It Cannot Be Edited


Created By: Lourdes Montoya On 08/11/2021 at 02:03 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
, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME: WELLSPRING MANOR SENIOR CARE INC
FACILITY NUMBER: 198320026

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/11/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on LPA's observation, the licensee did not comply with the section cited above. The hot water temperature in the common bathroom used by residents was measured at 136.8 degrees F. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/12/2021
Plan of Correction
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Licensee shall adjust the hot water temperature and maintain between 105-120 degrees F by 8/12/2021. Licensee shall document hot temperature checks every 4 hours for one week and submit the record by 8/17/2201
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:Angela J Kendrick
LICENSING EVALUATOR NAME:Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/02/2021 12:16 PM - It Cannot Be Edited


Created By: Lourdes Montoya On 08/11/2021 at 02:04 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
, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME: WELLSPRING MANOR SENIOR CARE INC
FACILITY NUMBER: 198320026

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/11/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observations and photos taken, items of potential hazards are stored in outdoor walkways. LPA observed two unrolled garden hoses, pails, brooms, chairs, old cabinet, bicycle, etc.
POC Due Date: 08/18/2021
Plan of Correction
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Licensee shall remove all obstructions in outdoor walkways by the POC due date. Licensee shall email photos of the cleared walkway to LPA Montoya.
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:Angela J Kendrick
LICENSING EVALUATOR NAME:Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2021


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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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
FACILITY NAME: WELLSPRING MANOR SENIOR CARE INC
FACILITY NUMBER: 198320026
VISIT DATE: 08/11/2021
NARRATIVE
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All rooms were inspected. Beds in shared bedrooms are 6 feet apart/3 feet head-to-toe apart. Beds and bedding supplies were in good condition, adequate lighting provided, storage for resident personal belongings was observed. LPA observed a fruit fly in the resident bedroom #1.

There are no security bars or weapons on the premises. Resident bathrooms were checked, sufficient liquid soap and paper towels were observed. Toilets and water faucets worked properly, grab bars were secure, the shower was free of mold/mildew, and a non-skid mat was in place. The water temperature measured at 136.8 degrees F. A comfortable temperature was maintained in the facility. Smoke detectors are interconnected and operational. LPA did not observe a carbon monoxide detector anywhere in the facility.

LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives and toxins were kept in a locked storage cabinet. LPA observed about about five to seven fruit flies in the kitchen. Centrally stored medications were observed stored in their originally received containers and kept safe and locked and inaccessible to clients in care. The First Aid kit was available. Two fire extinguishers last serviced on 4/12/2021 were observed in the dining area and the hallway near the bedrooms/bathroom.

Outside grounds were toured, and no bodies of water were observed. LPA observed potential hazards obstructing the walkways such as unrolled garden hoses, an old cabinet, cleaning supplies (brooms and pails) chairs, bicycle, etc.

Advisory Notes were issued, and Technical Assistance was provided.

Deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted and appeal rights discussed. A copy of this report and appeal rights provided to Staff Joel Morales.

SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2021
LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 09/02/2021 12:16 PM - It Cannot Be Edited


Created By: Lourdes Montoya On 08/11/2021 at 02:20 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
, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME: WELLSPRING MANOR SENIOR CARE INC
FACILITY NUMBER: 198320026

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/11/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(j)
(j) Care of Persons with Dementia: The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, interview, and record review, the licensee did not comply with the section cited above. Residents #2 & #3 have memory care needs. The licensee failed to ensure auditory devices in bedroom #2 and the sliding door in the living room are operable. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/25/2021
Plan of Correction
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LPA Montoya observed the auditory devices in bedroom #2 and living room have been fixed. This was corrected on today's visit.
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:Angela J Kendrick
LICENSING EVALUATOR NAME:Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/02/2021 12:16 PM - It Cannot Be Edited


Created By: Lourdes Montoya On 08/11/2021 at 02:27 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
, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME: WELLSPRING MANOR SENIOR CARE INC
FACILITY NUMBER: 198320026

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/11/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1503.2
Carbon Monoxide Detectors required. Every facility licensed or certified (pursuant to this chapter) shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation and interview, the licensee did not comply with the section cited above. LPA did not observe a carbon monixide detector anywhere in the facility. Administrator stated there is a working detector but a staff took it off from the outlet. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/12/2021
Plan of Correction
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Licensee installed a new and operable carbon monoxide detector in the hallway near the entrance. This was corrected on today's visit.
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:Angela J Kendrick
LICENSING EVALUATOR NAME:Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2021


LIC809 (FAS) - (06/04)
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