198320026-7-7-2023-11-AS-MVAO-CUYU4M-20230823151522

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320026
Report Date: 07/07/2023
Date Signed: 07/07/2023 04:23:17 PM

Unsubstantiated

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
06/12/2023 and conducted by Evaluator Ernand Dabuet

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20230612150547

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: 4	DATE:	07/07/2023
		UNANNOUNCED	TIME BEGAN:	08:02 AM
MET WITH:	Terisita Joy Maloncio		TIME COMPLETED:	11:59 AM

ALLEGATION(S):

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Unqualified staff accessing resident.
Staff unable to locate resident’s food.
Lack of supervision from staff causing resident to leave the facility.

INVESTIGATION FINDINGS:

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On 07/07/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent complaint visit at this facility. LPA was greeted by caregiver Terisita Joy Maloncio. Maloncio contacted House Manger Joel Morales and explained the purpose of the visit complete the investigation.

The investigation revealed the following: Interviews with staff #1-#4 (S1-S4) , resident #1- #5 (R1-R5), and witnesses #1- #2 (W1-W2). A review of (R1's) service records and other pertinent documents associated with this complaint. A review of staff and resident rosters. A tour of the facility was conducted.

(Evaluation Report continues on LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 07/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20230612150547

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: 07/07/2023

NARRATIVE

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INVESTIGATION REVEALED THE FOLLOWING:

Allegation: Unqualified staff accessing resident.

The details for the complaint alleged that an unqualified staff accessed resident #1 (R1) with a mental disorder. The complainant reported (R1) was assessed by a staff working at this facility and used the information to notify the hospice's medical director who accepted the data and diagnosed (R1) with Dementia. According to the complainant, (R1) is not suffering from Dementia and is able to carry out normal activities and engage in meaningful conversations with other residents. This diagnosis is disputed by the complainant for (R1).

The facility’s admission agreement for (R1) indicated on 03/29/22 was accepted for admission after being discharged from a local hospital 04/01/23. The medical discharge report did not indicate an assessment of (R1’s) mental condition. Based on a physician's report dated 03/28/22, (R1) is in fair health with no evidence of mild cognitive impairment or dementia. As a result, (R1) was later admitted under the care of Diamond Hospice Services Inc on 04/03/22 to 11/27/22. (R1) was diagnosed with Senile Degeneration of the Brain by a hospice physician. (R1) continued hospice care with Generations Hospice from 12/10/22 – 06/06/23 and was diagnosed with Alzheimer’s Disease. (R1) was discharged from Wellsprings Manor Senior Care on 06/12/23. (R1) was transferred to The Heavens at Antelope Valley on 06/08/23. A physician report dated 05/27/23 diagnosed with Dementia and resides in memory care. A review of hospice, medical, and service records revealed (R1's) family representatives had acknowledged (R1's) health condition verified with a signature.

An interview hospice representative (W1) stated (R1) was given a Mental Status Examination as (R1) was previously diagnosed by Diamond Hospice with Senility on 04/03/22. (W1) stated it is likely (R1's) condition will change within eight months of switching hospices. (R1) was admitted by Generations Hospice care. Based on the information gathered, the allegation mentioned above cannot be supported.

Allegation: Staff unable to locate resident’s food.

The details for the complaint alleged the staff was unable to provide proper meals to resident # 1 (R1). The complainant reported on 06/11/23 (R1) did not have dinner. (R1) only soup and had leftovers and did not offer a proper meal to (R1). (Evaluation Report continues LIC 9099-C)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 07/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2023

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20230612150547

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: 07/07/2023

NARRATIVE

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The Department reviewed progress notes for (R1) 06/02/23 – 06/11/23 (R1) meals were noted. According to staff #2 (S2), (R1) was adamant about only eating food that (R1) had purchased. The meals prepared for (R1) were according to (R1’s) preference and followed the physician’s orders. Each meal contained some protein, grains, vegetables, fruit, and dairy. Interviews with residents #2-#3 had no issues or concerns with their meals. (R2-R3) stated they received a balanced meal three times a day with a snack. Interviews with R4 and R5 were not possible due to their health condition and unable to hold a conversation. An interview with a family member witness (W2) expressed satisfaction with the services and meals provided by staff.
Based on the information gathered, there is no evidence to corroborate the allegation mentioned above.

Allegation: Lack of supervision from staff causing resident to leave the facility.

It is alleged due to a lack of supervision, resident #1 (R1) left the facility. The complainant stated on 06/08/23, the facility staff was unaware that (R1) left for the bank with a friend. The staff was uninformed of (R1’s) whereabouts and was away from the facility for several hours. An interview with staff #1-#2 (S1-S2) disputes this allegation. According to (S2), (R1) went out with a friend and was told by (R1) that the family representative was notified by (R1). (S2) made a call to the family representative to verify and was not able to get a hold of a family member. (R1) refused to be detained until (S2) was able to get a verification and left the facility with the friend disregarding (S2's) request to hold off. (S2) had noted this incident on (R1’s) progress notes. A review of (R1’s) physician's report dated 05/23/23, (R1) can leave the facility unassisted.

Interviews with (R2-R3) had no issues or concerns for their care of supervision with any staff. (R2-R3) were complimentary of staff. Interviews with R4 and R5 were not possible due to their health condition and unable to hold a conversation. An interview with a family member witness #2 (W2) found there is no immediate health or safety concern with the resident total care at this facility. Based on the information gathered, there is no evidence to support the allegation mentioned above.

Interviews could not be completed with (R1) to addressed these allegations.

(Evaluation Report continues LIC 9099-C)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 07/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2023

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20230612150547

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: 07/07/2023

NARRATIVE

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Based on information gathered, an inspection of the facility, observation, and interviews conducted, documents reviewed, the Department found no evidence to support the allegations mentioned above.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations, did or did not occur, therefore the allegations are Unsubstantiated.

An exit interview conducted with Terisita Joy Maloncio, and a copy of the report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 07/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2023

LIC9099 (FAS) - (06/04)

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