<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320026
Report Date: 02/13/2023
Date Signed: 02/13/2023 10:22:44 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 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
02/10/2023 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20230210132627
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:
02/13/2023
UNANNOUNCEDTIME BEGAN:
09:02 AM
MET WITH:Joel Morales & Teresita Bautista TIME COMPLETED:
04:03 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not issue a refund.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 02/13/23 Licensing Program Analyst (LPA) Ernand Dabuet conducted an initial complaint investigation for the allegation listed above. LPA was greeted by house manager Joel Morales and administrator Teresita Bautista. LPA explained the purpose of today's visit is to review and audit personnel record for resident in care.

The investigation consisted of record reviews. A review of the following documents: Resident roster, Staff roster, analysis of personnel records for resident #1 (R1). An nterview with house manager and licensee. An inteview with witness (W1). A tour of the facility and grounds was conducted to observe and identify any signs of neglect, abuse, or other threats to immediate health and safety.

Evaluation Report continue on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2023
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-20230210132627
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: WELLSPRING MANOR SENIOR CARE INC
FACILITY NUMBER: 198320026
VISIT DATE: 02/13/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
INVESTIGATION REVEALED THE FOLLOWING:
Allegation: Staff did not issue a refund.
It is alleged that the staff refuses to issue a refund. The complainant reported resident #1 (R1) was a former resident at this facility and was admitted on 05/10/21. However, before being admitted at Wellsprings Manor, (R1) spent a few days at Summer Breeze Manor. Both facilities are being operated by the same administrator Teresita Bautista.

The complainant claimed the power of attorney (POA) to (R1) was in charge of finances for (R1) and paid every 10th of each month $3500 for rent and services. (R1) was also charged an additional deposit fee of $3500 which was paid when the contract for the Admission Agreement was approved signed and dated 04/19/21. The $3500 amount appears on a separate invoice noted as one month deposit (refunded upon termination of service). The complainant claimed (R1) passed away on 01/05/23 and the facility refused to refund the $3500 deposit and the prorated amount of $583.33 for the (5) days for rent and services in January 2023. The complainant stated this facility owes a total amount of $4083.33. According to the complainant, the (POA) was in communication with the house manager with three messages. A written statement addressed to Morales dated 01/18/23 at 12:43 pm requesting a refund. An interview with the administrator (S1) and house manager (S2) confirmed they were in communication with the (R1's) (POA) in January 2023 and the most recent text messages with (S2) on 02/09/23 and 02/11/23. (S2) responded with a text message "the office will be refunding you the deposit amount." No mention of when and if the prorated amount will be refunded on the reply message. According to (S1) the reason for the delay was due to record keeping. Since all transactions were processed through Zelle, (S1) was unsure if a deposit was charged for Summer Breeze or Wellsprings. (S1) audited the payment history for Wellsprings and did not see a deposit charged for (R1). The (POA) was requested to provide a receipt. It was claimed that neither (S1) nor (S2) intended to not refund the money, but just wanted to verify the information.

Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has been met; the facility failed to refund fees paid in advance to the contractually responsible party within 15 days after the resident's death and removal of personal property as stated in Health and Safety 1569.652. Therefore, the allegation of: "Staff did not issue a refund" is found to be SUBSTANTIATED.

According to the California Code of Regulations (Title 22, Division 6, Health and Safety Code), the following deficiency has been observed and citation issued (ref. LIC 9099D).
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20230210132627
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 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: 02/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/27/2023
Section Cited
HSC
1569.562(c)
1
2
3
4
5
6
7
1569.652 Termination of admission agreement upon death of resident... refund of fees paid; notice of contract termination and refunds (c) A refund of any fees paid in advance covering the time after the resident’s .. removed from the facility shall be issued... responsible for the fees or, if the deceased resident paid the fees... within 15 days after the personal property is removed.
1
2
3
4
5
6
7
Licensee will develop a plan on to ensure any advance paid fees according to H&S 1569.652 are refunded within 15 days after death or/personal property is removed. Proof correction must be sent to LPA by fax by 02/27/23 at 323-981-1781.
8
9
10
11
12
13
14
This requirement was not met as evidence by:
Based on observations and interviews conducted, Licensee charged R1 a deposit fee and advance fee and did not issue a refund within 15 days This is a potential health and safety risk to clients in care.
8
9
10
11
12
13
14
*This citation was corrected during the visit when licensee refunded all fees due to POA.* Proof of correction was provided with registered mail receipt.
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3