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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320026
Report Date: 09/20/2024
Date Signed: 09/20/2024 04:21:45 PM

Document Has Been Signed on 09/20/2024 04:21 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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:WELLSPRING MANOR SENIOR CARE INCFACILITY NUMBER:
198320026
ADMINISTRATOR/
DIRECTOR:
BAUTISTA, TERESITAFACILITY TYPE:
740
ADDRESS:2260 W 236TH PLACETELEPHONE:
(310) 418-7938
CITY:TORRANCESTATE: CAZIP CODE:
90501
CAPACITY: 6CENSUS: 6DATE:
09/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:28 PM
MET WITH:Supervisor Joel MoralesTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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On 09/20/24, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced required – annual inspection and met with Teresita “Joy” Martinez. Supervisor Joel Morales joined us later.

The facility is licensed to for (6) six non-ambulatory, of which (4) four can be bedridden. Rooms #1, #2, and #3 are approved for bedridden. It is has an approved hospice waiver for four (4) residents. Annual fees are due 09/26/24.



The facility is a one-story house located in a residential neighborhood and consists of four (4) bedrooms, two (2) bathrooms, kitchen, living room/dining room, covered patio and a garage. The facility is clean, sanitary, and in good repair.

Staff accompanied LPA inside and outside the facility during this inspection. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards.

Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. There are no security bars or weapons on the premises. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, and hot water temperature properly measured between 120F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Continue to LIC809C.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: WELLSPRING MANOR SENIOR CARE INC
FACILITY NUMBER: 198320026
VISIT DATE: 09/20/2024
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Common areas were clean and clear of hazards, doorways were free of obstructions.

LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives and toxins were kept in locked storage cabinet. First Aid kit was available. One fire extinguisher, last serviced April 8, 2024 was observed in the dining room. Staff tested the carbon monoxide detector in the house. Device is functional.

Six (6) staff records were reviewed, 6 out of 6 staff records had the required criminal record clearances or criminal record exemptions.

Five (5) resident records were reviewed and, 5 out of 5 residents records had medical assessments and pre-appraisal or needs and services plans. Two residents’ medication was reviewed.

Due to insufficient time, an annual continuation is required.

An exit interview was conducted and a copy of this report was discussed and left with Supervisor Joel Morales.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024
LIC809 (FAS) - (06/04)
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