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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320026
Report Date: 09/12/2022
Date Signed: 09/12/2022 04:16:55 PM

Document Has Been Signed on 09/12/2022 04:16 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
MONTEREY 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: 6DATE:
09/12/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:TERESITA BAUTISTA/JOEL MORALESTIME COMPLETED:
04:00 PM
NARRATIVE
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This is an amended report. The administrator did not have signature on the original report.

On 9/12/2022, Licensing Program Analyst (LPA) Lourdes Montoya conducted a unannounced case management - deficiency visit observed during an unrelated complaint visit. LPA met with Administrator Teresita Bautista (S1) and and three staff (S2-S4).

Deficiencies:
1) Based on LPA's interview with S4, he began working in this facility on 8/22/2022 on a part-time basis. S4 stated he works on Mondays and Tuesdays, 6:00 am:7:00 pm. S4 stated he is a caregiver and he provides ADL care to residents. During LPA's interview with Staff 2, S4 has a background clearance under a different facility. S4 stated he has not submitted a transfer of clearance for S4 to CCLD.

2) During LPA's tour of the facility, LPA observed the garage is cluttered with boxes, frame frame, used wheelchairs, oxygen tank and other miscellaneous items.

A technical violation is used to licensee.

Deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. A civil penalty of $500 was assessed.

Failure to correct the deficiencies may result in additional civil penalties.

Exit interview conducted and appeal rights discussed. A copy of this report and appeal rights provided to Administrator Teresita Bautista.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE: DATE: 09/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2022
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 09/12/2022 04:16 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 09/12/2022 04:14 PM


Created By: Lourdes Montoya On 09/12/2022 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/13/2022
Section Cited
CCR
87355(e)(2)

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(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c). This requirement was not met as evidenced by:
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Administrator submitted a transfer of clearance (LIC 508) for Staff #4 to LPA Montoya. This deficiency is cleared on today's visit.
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Based on LPA's interview with S4, he began working in this facility on 8/22/2022 on a part-time basis. S4 stated he works on Mondays and Tuesdays, 6:00 am:7:00 pm. S4 stated he is a caregiver and he provides ADL care to residents. During LPA's interview with Staff#2, S4 has a background clearance under a different facility. S2 stated he has not submitted a transfer of clearance for S4 to CCLD.
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CIVIL PENALTY ASSESSED.
Type B
09/19/2022
Section Cited
CCR87303(a)

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(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by:
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Administrator agreed to organize the stuff in the garage. Administrator shall send a proof of correction to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date, 9/19/2022.
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 During LPA's tour of the facility, LPA observed the garage is cluttered with boxes, frame frame, used wheelchairs, oxygen tank and other miscellaneous items.
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This is an amended report. Administrator did not have a signature on the original report.
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:Eva M Alvarez
LICENSING EVALUATOR NAME:Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2022


LIC809 (FAS) - (06/04)
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