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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320026
Report Date: 12/02/2021
Date Signed: 12/03/2021 12:49:52 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/02/2021 and conducted by Evaluator Lourdes Montoya
COMPLAINT CONTROL NUMBER: 11-AS-20211102130928
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:
12/02/2021
UNANNOUNCEDTIME BEGAN:
09:43 AM
MET WITH:Teresita BautistaTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Resident sustained blood clots while in care.
Resident sustained UTIs while in care.
Staff yells at resident.
Facility is not free of trash.
Staff not smoking in designated areas.
INVESTIGATION FINDINGS:
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On 11/23/2021, Licensing Program Analyst (LPA) Lourdes Montoya conducted an unannounced subsequent complaint visit at this facility. LPA met with Administrator Teresita Baustisa and explained the purpose of today's visit is to gather additional information and deliver findings for allegations mentioned above.

The investigation consisted of the following: LPA inquired questions relevant to the nature of the complaint. LPA Lourdes Montoya conducted interviews with Staff (S1-S5) on 11/12/2021 and resident (R2) on 11/16/2021. LPA was unable to interview Residents (R3-R5) because R3 has mild cognitive impairment and did not want to pay attention to LPA’s questions, R4 has dementia and R5 was asleep during the visit on 11/16/2021. LPA called and interviewed a former resident (R1) on 11/17/2021. A tour of the facility’s outside grounds on 11/12/021 was conducted and both inside and outside grounds of the facility were also checked on 11/16/2021. LPA obtained residents’ (R1) service records, residents’ (R2-R5) physician’s reports; facility roster and staff roster.

Report continued in LIC 9099C

Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 11-AS-20211102130928
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/02/2021
NARRATIVE
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INVESTIGATION REVEALED THE FOLLOWING:

Resident (R1), the alleged victim, was admitted at Wellspring Manor Senior Care Inc on 3/1/2021. The physician’s report obtained from the facility was dated 12/8/2020. LPA obtained copies of R1’s Doctor's Clinic and hospital After Visit Summaries (AVS). The facility provided the department with two appraisals dated 3/1/2021 and 6/1/2021 which do not reflect the significant changes of R1’s medical condition during her stay in this facility. R1 was discharged from the facility on 11/10/2021.

Allegation: Resident sustained blood clots while in care.



It is alleged Resident sustained blood clots while in care. The complainant reported the alleged victim, Resident (R1), was observed with a lot of pain from blood clots. Based on record review of R1’s AVS dated 9/9/2021, R1 sustained a chronic deep venous thrombosis (DVT) of both legs, leg pain, right leg pain, and deconditioning. According to the review of AVS, on 11/1/2021, R1 was prescribed Enoxaparin to prevent blood clots in the leg; On 11/13/2021, R1 was admitted to Kaiser Permanente and she was diagnosed with Pulmonary Embolism upon her discharge on 11/16/2021. Interview with Staff (S1-S5) and Residents (R1-R2), they did not see symptoms that R1 has a blood clot. Staff (S1-S5) just learned that she has a blood clot when she was discharged from the hospital. Based on the information gathered, there is no evidence that staff were negligent and therefore there is no sufficient evidence to corroborate the allegation mentioned above.

Allegation: Resident sustained UTI while in care.

It is alleged Resident sustained Urinary Tract Infection (UTI) while in care. The complainantt reported the alleged victim, Resident (R1), was transferred to the hospital three (3) times due to UTI. Interview with Staff (S1-S4) revealed R1 sustained UTI, however, S1 stated the caregivers clean and wash R1 at least three times a day to avoid infection. Residents (R1-R2) and staff (S5) stated they have no knowledge of any residents sustaining UTI while in care. Based on review of R1’s admission agreement, she was admitted to this facility on 3/1/2021. Based on R1’s medical records, she was admitted to the hospital on 6/14/2021, 10/30/2021, and 11/13/2021 due to UTI. However, based on record review of R1’s After Visit Summary at South Bay Medical Center dated 2/23/2021 – 2/24/2021 shows R1 was provided with Patient education on Urinary Tract

Report Continued in LIC 9099C

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
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 11-AS-20211102130928
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/02/2021
NARRATIVE
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Infection, no other records were attached to the summary. Record review revealed R1 has a history of UTI prior to admission at this facility. Based on the information gathered, there is no sufficient evidence to corroborate the allegation mentioned above.

Allegation: Staff yells at a resident.


It is alleged facility staff yells at a resident. The complainant reported there is a nurse who yells at one of the residents, they argued about everything. Based on the Department’s interview with Staff (S1-S3), a former staff (S6) had an encounter with Resident #2 who continues to yell at all staff; he calls them names, he demands them what to do in the home; he curses at them too. Staff (S1-S3) stated S6 resigned from his job because he could no longer handle the attitude of R2. S1 admitted S6 responded anxiously when R2 cursed at S6. Interview with Staff (S4-S5) and residents (R1-R2) revealed no staff yells at residents. Based on the information gathered, there is no sufficient evidence to corroborate the allegation mentioned above.

Allegation: Facility is not free of trash.

It is alleged facility is not free of trash. The complainant reported she observed a lot of cigarette buds around the facility. Interview with Residents (R1-R2) and Staff (S1-S5) revealed the facility is free of trash and it is clean every day. Based on LPA’s observation, the facility is clean, and no cigarette buds were observed around the outside and inside grounds of the facility. Based on the information gathered, there is no evidence to corroborate the allegation mentioned above.

Allegation: Staff not smoking in designated areas.

It is alleged Staff are not smoking in designated areas. The complainant reported she observed construction workers smoking too close to the facility. Record review shows the designated smoking area is the driveway area of the home or 25 feet away from the main door of the home. Interview with Residents (R1-R2) and Staff (S1-S5) revealed no staff smoke cigarettes close to the facility. S2 and S4 admitted they smoke in the designated areas. Based on LPA’s observation during her complaint visit on 11/12/2021, she observed S1 smoking in the designated area of the premises. Based on the information gathered, there is no sufficient evidence to corroborate the allegation mentioned above.



REPORT CONTINUED IN LIC 9099-C
SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 11-AS-20211102130928
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/02/2021
NARRATIVE
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Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, "Resident sustained blood clots while in care", "Resident sustained UTIs while in care", "Staff yells at resident", "Facility is not free of trash", "Staff not smoking in designated areas" did or did not occur, therefore the allegation is unsubstantiated.

No deficiencies cited, Exit Interview conducted, and report given to Administrator Teresita Bautista.
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
LIC9099 (FAS) - (06/04)
Page: 4 of 4