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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320026
Report Date: 01/10/2024
Date Signed: 01/10/2024 02:12:04 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/06/2022 and conducted by Evaluator Felisa Shirley
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20220906094918
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: 5DATE:
01/10/2024
UNANNOUNCEDTIME BEGAN:
01:33 PM
MET WITH:Joel Morales, SupervisorTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Staff handle resident in a rough manner
Staff makes inappropriate comments towards resident
Staff makes inappropriate comments about resident to other residents
Staff makes inappropriate gestures towards resident
Staff are not providing a comfortable environment for resident
Resident is being threatened with an eviction
INVESTIGATION FINDINGS:
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On 1/10/24, Licensing Program Analyst (LPA) Felisa Shirley conducted a subsequent complaint visit at this facility to deliver the complaint investigation findings. Upon arrival, LPA met with Joel Morales, Supervisor, who assisted with the visit. LPA explained the purpose of today's visit.

The investigation consisted of the following: On 9/12/2022, LPA Montoya toured the facility with Administrator Teresita Bautista. LPA interviewed four out of four staff (S1-S4) and four out of six residents (R1-R4). LPA was unable to interview two Residents (R5-R6) due to their medical conditions. LPA requested and obtained R1’s service records (Admission Agreement, Physician’s Report, Appraisals/Needs and Services Plans, incident reports), the facility’s staff roster, resident roster, house rules/ policies, and other pertinent records.


INVESTIGATIONS REVEALED THE FOLLOWING:

Con'd on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2024
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 5
Control Number 11-AS-20220906094918
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: WELLSPRING MANOR SENIOR CARE INC
FACILITY NUMBER: 198320026
VISIT DATE: 01/10/2024
NARRATIVE
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Allegation: Staff handle resident in a rough manner.

It is alleged that staff handle resident in a rough manner. On 9/12/2022, LPA Lourdes Montoya interviewed four out of four staff (S1-S4) and four out of six residents (R1-R4). LPA was unable to interview two Residents (R5-R6) due to their medical conditions. Based on interviews conducted, three out of four residents and four out of four staff denied that staff handled residents in a rough manner. One out of four residents claimed one staff is very rough on R1. Two out of four staff claimed R1 is rough on staff and residents. Based on records review, incident reports were submitted to the department indicating that R1 was aggressive to staff and/or residents. Based on LPA’s observations, no staff handled any resident in a rough manner. LPA observed R1 is rough to residents, staff and to the LPA. Based on information gathered, there is no sufficient evidence to corroborate the above allegation.

Allegation: Staff makes inappropriate comments towards resident.

It is alleged that staff makes inappropriate comments towards resident. On 9/12/2022, LPA Lourdes Montoya interviewed four out of four staff (S1-S4) and four out of six residents (R1-R4). LPA was unable to interview two Residents (R5-R6) due to their medical conditions. Based on interviews conducted, three out of four residents and four out of four staff denied that staff makes inappropriate comments towards a resident. One out of four residents claimed one staff made inappropriate comments towards R1. Two out of four staff claimed R1 is rude to staff and residents. Based on records review, incident reports were submitted to the department indicating that R1 was rude to staff and/or residents. Based on LPA’s observations, no staff made inappropriate comments towards any resident. LPA observed R1 is rude to residents, staff and to the LPA. Based on information gathered, there is no sufficient evidence to corroborate the above allegation.

Allegation: Staff makes inappropriate comments about resident to other residents.

It is alleged that staff makes inappropriate comments about resident to other residents. On 9/12/2022, LPA Lourdes Montoya interviewed four out of four staff (S1-S4) and four out of six residents (R1-R4).

Con'd on 9099-C
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 11-AS-20220906094918
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: WELLSPRING MANOR SENIOR CARE INC
FACILITY NUMBER: 198320026
VISIT DATE: 01/10/2024
NARRATIVE
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). LPA was unable to interview two Residents (R5-R6) due to their medical conditions. Based on interviews conducted, three out of four residents and four out of four staff denied that staff makes inappropriate comments about resident to other residents. One out of four residents claimed all staff are talking about R1. Two out of four staff claimed R1 made comments about them to other staff that they are having inappropriate activities in the facility. Based on records review, there are no incident reports that staff are talking about R1 to other residents. Based on LPA’s observations, R1 made inappropriate comments to LPA about staff. Based on information gathered, there is no sufficient evidence to corroborate the above allegation.

Allegation: Staff makes inappropriate gestures towards resident.

It is alleged that staff makes inappropriate gestures towards resident. On 9/12/2022, LPA Lourdes Montoya interviewed four out of four staff (S1-S4) and four out of six residents (R1-R4). LPA was unable to interview two Residents (R5-R6) due to their medical conditions. Based on interviews conducted, three out of four residents and four out of four staff denied that staff makes inappropriate gestures towards resident. One out of four residents claimed one staff made an inappropriate act by pointing a middle finger at R1. One out of four staff claimed R1 made inappropriate acts to staff by pointing a middle finger at them. Based on records review, there are no incident reports that staff made inappropriate gestures towards any resident. LPA did not observe any staff making inappropriate gestures towards residents. LPA observed staff are polite to residents. Based on information gathered, there is no sufficient evidence to corroborate the above allegation.

Allegation: Staff are not providing a comfortable environment for resident.

It is alleged that staff are not providing a comfortable environment for resident. On 9/12/2022, LPA Lourdes Montoya interviewed four out of four staff (S1-S4) and four out of six residents (R1-R4).

Con'd on 9099-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 11-AS-20220906094918
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: WELLSPRING MANOR SENIOR CARE INC
FACILITY NUMBER: 198320026
VISIT DATE: 01/10/2024
NARRATIVE
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). LPA was unable to interview two Residents (R5-R6) due to their medical conditions. Based on interviews conducted, three out of four residents and four out of four staff denied that staff are not providing a comfortable environment for residents. One out of four residents claimed one staff refused to assist R1 and this caused R1 to be uncomfortable. Three out of four staff claimed R1 makes staff and other residents uncomfortable by yelling at them, showing them inappropriate gestures, throwing things at them and calling them inappropriate names. Based on records review, incident reports were submitted to the department indicating that R1 was aggressive to staff and/or residents that creates the environment uncomfortable for staff and residents. There are no incident reports indicating that staff is not providing a comfortable environment for residents. LPA observed staff are quiet and LPA did not observe any behavior that would cause an uncomfortable environment to residents. LPA observed R1’s behavior and comments creating an uncomfortable environment to residents, staff and to the LPA. Based on information gathered, there is no sufficient evidence to corroborate the above allegation.

Allegation: Resident is being threatened with an eviction.

It is alleged that resident is being threatened with an eviction. On 9/12/2022, LPA Lourdes Montoya interviewed four out of four staff (S1-S4) and four out of six residents (R1-R4). LPA was unable to interview two Residents (R5-R6) due to their medical conditions. Based on interviews conducted, three out of four residents and four out of four staff denied that resident is being threatened with an eviction. One out of four residents claimed R1 received an eviction letter six times since last year. R1 used to read them but recently R1 just threw the eviction letters away and does not want to leave the facility. Two out of four staff revealed the facility served R1 with an eviction letter several times due to failure to follow the facility’s policies but R1 refused to leave the facility and continued to harass staff and residents. Based on records review, the facility served a 30-day eviction notice to R1 on 7/20/2022. Based on LPA’s observations, R1 was not threatened with an eviction. R1 was advised by licensee to stop violating the community’s policies if R1 desires to stay in the facility. LPA observed the licensee considered retaining R1 if R1 refrains from violating the facility’s policies. Based on information gathered, there is no sufficient evidence to corroborate the above allegation.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20220906094918
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: WELLSPRING MANOR SENIOR CARE INC
FACILITY NUMBER: 198320026
VISIT DATE: 01/10/2024
NARRATIVE
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Based on records review, interviews and observations, LPA did not find sufficient evidence to support the above allegations. Although the allegations may have happened or are 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 was conducted, and a copy of the LIC 9099 report was provided to Joel Morales, Supervisor
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5