198320026-9-27-2022-11-AS-JHAD-CKTQUK-20221103122851

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320026
Report Date: 09/27/2022
Date Signed: 09/27/2022 03:56:14 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
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/22/2022 and conducted by Evaluator Ana Soto

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20220922144101

FACILITY NAME:	WELLSPRING MANOR SENIOR CARE INC		FACILITY NUMBER:	198320026
ADMINISTRATOR:	BAUTISTA, TERESITA		FACILITY TYPE:	740
ADDRESS:	2260 W 236TH PLACE		TELEPHONE:	(310) 418-7938
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90501
CAPACITY:	6	CENSUS: 5	DATE:	09/27/2022
		UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Joel Morales, Supervisor		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Night staff did not respond to residents call for assistance.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ana Soto conducted an initial complaint investigation for the allegation listed above. Today’s complaint investigation was conducted with Joel Morales, Supervisor.

The investigation consisted of following: Interviews and Record reviews. On 09/27/22, LPA Soto interviewed S#1 - S#5. R#1 - R#5, and W#1 (via telephone). LPA requested and received the following documents: Resident roster, Staff roster, R#1 file ( Face sheet, Admission agreement, ID/Emergency Information, Consent for Emergency Medical Treatment, Pre-appraisal, Physician's report (dated 05/22/20), Needs and Services Plan, Mars -August & September, 2022.) Torrance Police Report #, Pictures and video of incident dated 09/08/22 (text,) and 4 Incident reports.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2022

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 3

Control Number 11-AS-20220922144101

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
MONTEREY PARK, CA 91754

FACILITY NAME: WELLSPRING MANOR SENIOR CARE INC	FACILITY NUMBER: 198320026
	VISIT DATE: 09/27/2022

NARRATIVE

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Based on the LPA's investigation, the investigation revealed the following. Allegation – Night staff did not respond to residents call for assistance. Interviews with staff #2 - #5 denied not responding to a bell when resident #1 requested assistance. All the staff agreed that they always respond to all the residents calls for assistance. They check on the residents 2x a night to make sure they are okay and if they might need assistance. There's one resident that needs help at least 2 to 3 times a night to go to the restroom, so they are always ready to assist any resident at any time. Sometimes the resident do not ask for assistance at night, but they still checked on them 2x a night. The staff are all live in staff and can hear the bell from any where inside the facility. Staff #1 & S#2, both agreed that R#1 needs a higher level care. R#1 refuses to let S#2 talk to R#1 doctor to see if R#1 needs new medication. R#1 has been very abusive towards S#3-S#5. R#1 has physically hit S#2 & S#3 and they refuse to press charges against R#1. There was an incident on 09/08/22, where R#1 broke a vase through on the floor and the Police was called. At that time, Police did not arrest R#1, just spoke with R#1. S#1 called the PET team for R#1, but they stated that R#1 did not meet the criteria and could to take R#1 with them. S#1 & S#2 agree that R#1 needs a higher level of care, but refuses to accept it. LPA reviewed video and pictures of the incident that occurred 09/08/22, it demonstrated R#1 yelling and picking up case and throwing the flowers and vase to the floor. Interviews with R#2, stated that care givers are great, they do a wonderful job of taking care of R#2. R#1 has to go because R#1 is always yelling at the staff and being really mean. R#1 in R#2 opinion needs be in a mental institution and requires mental medication and psychiatric help. R#1 does not belong at the facility. Interview with R#3, was not possible, R#3 was not able to communicate with LPA. Interview with R#4, R#4 refused to speak with LPA. Interview with R#5, stated that the care givers are good and R#1 has a short temper, always mad. Interview with W#1, stated that W#1 has had bad experiences with R#1, W#1 has been going to assist resident at the facility for the last six months. Every time W#1 comes across R#1, R#1 always cursing, yelling, and saying bad words to W#1. W#1 doesn't even inter-act with R#1, R#1 doesn't get assistance from W#1, but without any provocation R#1 just lashing out at W#1. W#1 tries to make sure W#1 doesn't say or do anything that will cause R#1 any agitation.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2022

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20220922144101

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
MONTEREY PARK, CA 91754

FACILITY NAME: WELLSPRING MANOR SENIOR CARE INC	FACILITY NUMBER: 198320026
	VISIT DATE: 09/27/2022

NARRATIVE

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LPA reviewed R#1 MARS (August and September) R#1 is not taking any medication for any mental disability. Interview with R#1, stated that all the care givers are liars and do not know what they are doing, they need to get rid of all of them. R#1 has been at the facility for 3 years and in all the time they only had one good care giver. They need to replace all the care giver and get new ones. LPA also reviewed R#1 Physician's report dated 05/22/20, it does not state any mental disability only has physical conditions. When LPA interviewed R#1, R#1 seemed frustrated and anxious and admitted to breaking the vase and throwing the flowers. Incident dated 07/07/22, 07/08/22, & 07/10/22, all state R#1 cursing and yelling at staff. The records reviewed and interviews conducted did not concur with the above allegation.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated

An exit interview was conducted with Joel Morales, Administrator, and a hard copy of report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2022

LIC9099 (FAS) - (06/04)

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