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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320026
Report Date: 09/25/2024
Date Signed: 09/25/2024 10:08:48 AM

Document Has Been Signed on 09/25/2024 10:08 AM - 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: 5DATE:
09/25/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:25 AM
MET WITH:Supervisor Joel MoralesTIME VISIT/
INSPECTION COMPLETED:
10:25 AM
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On 09/25/24, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced annual continuation inspection and met with Supervisor Joel Morales.

LPA Cloyd reviewed training records.

An exit interview was conducted, technical assistance provided, 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: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/25/2024
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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