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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320026
Report Date: 08/29/2025
Date Signed: 08/29/2025 01:28:01 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
08/22/2025 and conducted by Evaluator Troy Watson
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20250822100821
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:
08/29/2025
UNANNOUNCEDTIME BEGAN:
08:08 AM
MET WITH:Care Giver - Vina SimaputangTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Staff left resident in soiled daipers.
Staff did not safeguard resident's personal belongings.
Staff did not ensure the showers were not in disrepair.
Staff did not ensure resident's bed was not in disrepair.
Staff did not ensure the facility had toiletries.
Staff are not providing adequate food service to resident's.
Staff are not meeting resident's shower needs.
INVESTIGATION FINDINGS:
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On 08/29/2025 Licensing Program Analyst (LPA)Troy Watson made a subsequent complaint visit to the facility listed above and was greeted by the Care Giver Vina Simatupang. LPA explained the purpose of the visit was to deliver findings and was granted access to the facility grounds.

The investigation consisted of the following:

On 08/28/2025 Licensing Program Analyst (LPA) Troy Watson requested, reviewed, and obtained copies of the Staff Roster, Resident Roster, Physicians Reports, Appraisal Needs and Services and Facility Food Menu. On 08/28/2025 LPA Watson interviewed Staff #1 – Staff #3 (S1-S3) and Residents #1 – Residents #4 (R1-R4). An attempt to interview Resident #5 (R5) was made but due to dementia no interview was able to be made.LPA Watson toured the facility with the Facility Supervisor Joel Morales.

CONTINUED ON LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2025
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-20250822100821
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: 08/29/2025
NARRATIVE
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The Investigation revealed the following

Allegation: Staff left resident in soiled diapers

On 08/28/2025 LPA Watson conducted interviews with Residents #1- Residents #4 (R1-R4) and Staff #1-Staff #3 (S1-S3). An attempt to interview #5 was made, but because of dementia (R5) was not included in the outcome of the investigation. On 08/28/2025 LPA Watson interviewed Residents #1 – Residents #4 regarding the above allegation. Out of those interviewed, 4 out of 4 denied the allegation. On 08/28/2025 LPA Watson interviewed Staff #1 – Staff #3 (S1-S3). Out of those interviewed 3 out of 3 denied the allegation. LPA was told by everyone interviewed that diapers were changed regularly three or more times a day. Based on the information gathered, interviews conducted, and an analysis of records reviewed, LPA Watson found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur therefore the allegation is Unsubstantiated.

Allegation: Staff did not safeguard resident's personal belongings.

On 08/28/2025 LPA Watson conducted interviews with Residents #1- Residents#4 and Staff #1-Staff #3 (S1-S3). An attempt to interview #5 was made, but because of dementia (R5) was not included in the outcome of the investigation. On 08/28/2025 LPA Watson interviewed Residents #1 – Residents #4 regarding the above allegation. Out of those interviewed, 4 out of 4 denied the allegation. On 08/28/2025 LPA Watson conducted interviews with Staff #1 – Staff #3 (S1-S3). Out of those interviewed 3 out of 3 denied the allegation. LPA toured the facility and found that resident’s personal belongings were located inside their bedrooms in drawers. The Facility Supervisor Joel Morales stated that he only allowed residents to keep clothes and nothing valuable in their rooms. Every resident interviewed stated that they have never experienced any theft. Based on the information gathered, interviews conducted, and review of records LPA Watson found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is Unsubstantiated.

CONTINUED ON LIC9099-C
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 11-AS-20250822100821
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: 08/29/2025
NARRATIVE
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Allegation: Staff did not ensure the showers were not in disrepair.

On 08/28/2025 LPA Watson conducted interviews with Residents #1- Residents#4 and Staff #1-Staff #3 (S1-S3). An attempt to interview #5 was made, but because of dementia (R5) was not included in the outcome of the investigation. On 08/28/2025 LPA Watson interviewed Residents #1 – Residents #4 regarding the above allegation. Out of those interviewed, 4 out of 4 denied the allegation. On 08/28/2025 LPA Watson conducted interviews with Staff #1 – Staff #3 (S1-S3) regarding the above allegation. Out of those interviewed 3 out of 3 denied the allegation. LPA Watson toured the facility with the Facility Supervisor Joel Morales and observed the bathroom and shower clean and in good repair. Based on the information gathered, interviews conducted, and an analysis of records reviewed, LPA Watson found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is Unsubstantiated.

Allegation: Staff did not ensure residents’ bed was not in disrepair.

On 08/28/2025 LPA Watson conducted interviews with Residents #1- Residents#4 and Staff #1-Staff #3 (S1-S3). An attempt to interview #5 was made, but because of dementia(R5) was not included in the outcome of the investigation. On 08/28/2025 LPA Watson interviewed Residents #1 – Residents #4 regarding the above allegation. Out of those interviewed, 4 out of 4 denied the allegation. On 08/28/2025 LPA Watson conducted interviews with Staff #1 – Staff #3 (S1-S3) regarding the above allegation. Out of those interviewed 3 out of 3 denied the allegation. LPA Watson inspected the beds in each room with the Care Giver Vina Simatupang and confirmed that each remote-controlled bed was working and in good repair. Based on the information gathered, interviews conducted, and an analysis of records reviewed, LPA Watson found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is Unsubstantiated.



CONTINUED ON LIC9099-C
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 11-AS-20250822100821
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: 08/29/2025
NARRATIVE
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Allegation: Staff did not ensure the facility had toiletries.

On 08/28/2025 LPA Watson conducted interviews with Residents #1- Residents#4 and Staff #1-Staff #3 (S1-S3). An attempt to interview #5 was made, but because of dementia (R5) was not included in the outcome of the investigation. On 08/28/2025 LPA Watson interviewed Residents #1 – Residents #4 regarding the above allegation. Out of those interviewed, 4 out of 4 denied the allegation. On 08/28/2025 LPA Watson conducted interviews with Staff #1 – Staff #3 (S1-S3) regarding the above allegation. Out of those interviewed 3 out of 3 denied the allegation. LPA Watson toured the facility with the Facility Supervisor Joel Morales and observed the facility fully stocked and adequately supplied with toiletries. Based on the information gathered, interviews conducted, and an analysis of records reviewed, LPA Watson found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is Unsubstantiated.

Allegation: Staff are not providing adequate food service to residents.

On 08/28/2025 LPA Watson conducted interviews with Residents #1- Residents#4 and Staff #1-Staff #3 (S1-S3). An attempt to interview #5 was made, but because of dementia(R5) was not included in the outcome of the investigation. On 08/28/2025 LPA Watson interviewed Residents #1 – Residents #4 regarding the above allegation. Out of those interviewed, 4 out of 4 denied the allegation. On 08/28/2025 LPA Watson conducted interviews with Staff #1 – Staff #3 (S1-S3) regarding the above allegation. Out of those interviewed 3 out of 3 denied the allegation. LPA Watson requested and obtained a menu of the food served at the facility and it showed that residents were served meals three times a day. LPA observed the facility refrigerator fully stocked with various kinds of fruit, vegetables and meat. LPA Watson observed all meals served to the residents at the facility for breakfast, lunch and dinner and observed the residents being served nutritious meals. Based on the information gathered, interviews conducted, and an analysis of records reviewed, LPA Watson found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is Unsubstantiated.


CONTINUED ON LIC9099-C
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20250822100821
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: 08/29/2025
NARRATIVE
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Allegation: Staff are not meeting residents’ shower needs.

On 08/28/2025 LPA Watson conducted interviews with Residents #1- Residents#4 and Staff #1-Staff #3
(S1-S3). An attempt to interview #5 was made, but because of dementia (R5) was not included in the outcome of the investigation. On 08/28/2025 LPA Watson interviewed Residents #1 – Residents #4 regarding the above allegation. Out of those interviewed, 4 out of 4 denied the allegation. On 08/28/2025 LPA Watson conducted interviews with Staff #1 – Staff #3 (S1-S3) regarding the above allegation. Out of those interviewed 3 out of 3 denied the allegation. LPA Watson conducted interviews with each resident regarding their shower needs, and the residents stated that the care givers assisted in meeting their showering needs. Based on the information gathered, interviews conducted, and an analysis of records reviewed, LPA Watson found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is Unsubstantiated.

An exit interview was conducted with the Care Giver Vina Simatupang and a copy of this report was provided
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5