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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320026
Report Date: 11/16/2021
Date Signed: 12/17/2021 11:14:38 AM

Document Has Been Signed on 12/17/2021 11:14 AM - 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: 4DATE:
11/16/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:MYRA MAPALADTIME COMPLETED:
05:00 PM
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On 11/16/2021, Licensing Program Analyst (LPA) Lourdes Montoya conducted an unannounced case management - deficiency visit.

This deficiency was observed during a complaint visit at this facility on 11/12/2021. During the interview with facility staff and the administrator, it was confirmed that there was a construction in the facility. LPA observed the common bathroom floor and wall tiles were changed. Licensee failed to notify CCLD prior to the construction.

A deficiency is being cited on the attached LIC 9099D. Exit interview conducted. Copy of this report and appeal rights explained.
SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE: DATE: 12/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/02/2021
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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Document Has Been Signed on 12/17/2021 11:14 AM - It Cannot Be Edited


Created By: Lourdes Montoya On 11/22/2021 at 11:34 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: 11/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/22/2021
Section Cited
CCR
87305(a)

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87305 Alterations to Existing Building or New Facilities (a) Prior to construction or alterations, all facilities shall obtain a building permit.

This requirement is not met as evidenced by:
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The licensee shall submit a letter to CCLD and explain the nature of the construction and how residents were handled to ensure their health and safety. Licensee will also review the Section on Title 22 related to this defiiciency and submit a self-certification by the POC due date to Lourdes.Montoya@dss.ca.gov.
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On 11/12/2021, based on LPA's interviews with five staff (S1-S5), the floor tiles in the common restroom were removed and new tiles were installed. On 11/16/2021, LPA Montoya observed the restroom has new floor and wall tiles. The administrator admitted she did not inform CCLD prior to construction. This poses a potential risk to health, safety or personal rights risk to residents in care.
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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: 11/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2021


LIC809 (FAS) - (06/04)
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