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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603040
Report Date: 06/15/2022
Date Signed: 06/15/2022 03:34:11 PM

Document Has Been Signed on 06/15/2022 03:34 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:SPRINGVILLEFACILITY NUMBER:
198603040
ADMINISTRATOR:FAN, LINDA LFACILITY TYPE:
740
ADDRESS:12755 TORCH STTELEPHONE:
(626) 337-7288
CITY:BALDWIN PARKSTATE: CAZIP CODE:
91706
CAPACITY: 43CENSUS: 32DATE:
06/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Staff Xiaohong Anna DongTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Nune Margaryan conducted an annual required visit. LPA met with 2 staff Staff 1 (S1) and Staff 2 (S2). S1 was determined to not have a criminal record clearance.
Shortly after Administrator Linda Fan arrived. The reason for the visit was explained. LPA used the infection control tool to evaluate the facility. LPA observed the physical plant, COVID-19 procedures, reviewed residents' medications, observed food supply, and reviewed staff files. The facility cares for elderly residents and is allowed to have 10 hospice residents. There are currently 3 residents on hospice.
LPA and Administrator toured the facility which included a random sample of resident rooms along with the kitchen, dining room, linen room, upstairs and downstairs lobbies, laundry room and medication room. The backyard patio area is well maintained and there are no pools or large bodies of water. There is a shaded seating area for the residents located in the patio area. Passageways and exits are free of obstruction.
The common areas are clean and have the required furniture. There is a screening station at the entrance of the facility which has PPEs and a thermometer to screen visitors. Staff document resident temperatures daily and require visitors to sign in. Facility currently has at least a 30-day supply of PPEs. The resident bathrooms have the required grabs bars and non-skid mat.
The water temperature was tested in a random selection of resident bathrooms. Hot water temperature measured at 122.2 degree F in bathroom #201 and in share bathroom for the rooms #202 and # 203.
Resident bedrooms have the required furniture such as bed frames, dressers, lamps and chairs. Bedrooms also have sufficient closet space. Resident beds have the required linen and the linen is in good condition.

Continue 809C.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE: DATE: 06/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/15/2022
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SPRINGVILLE
FACILITY NUMBER: 198603040
VISIT DATE: 06/15/2022
NARRATIVE
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Smoke detectors were observed throughout the facility and were tested and operable during the visit. There is several carbon monoxide detectors throughout the hallways of the facility. There are several fire extinguisher located throughout the facility. Kitchen appliances are clean and were operating at the time of the visit. Sharps are locked in the kitchen and are inaccessible to residents. Cleaning supplies and toxins were observed in the laundry room unlocked and accessible to residents.
LPA reviewed 3 resident records to confirm emergency contact is updated, physician's reports are on file, and admission agreements are complete. Two staff records were reviewed to confirm health screenings, training and fingerprint clearances. LPA reviewed 3 residents' medications. Medications are documented properly and given as prescribed. First Aid kit was fully stocked with current manual.

Per California Code of Regulations, Title 22, the deficiencies observed are documented on the attached 809D. Exit interview held. A copy of the report and appeal rights were provided to Administrator.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 06/15/2022 03:34 PM - It Cannot Be Edited


Created By: Nune Margaryan On 06/15/2022 at 02:08 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SPRINGVILLE
FACILITY NUMBER: 198603040

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(2)
87355 Criminal Record Clearance. (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2)Request a transfer of a criminal record clearance as specified in Section 87355(c)....

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above. During the visit LPA observed that staff Staff 1 (S1) was not have a criminal record clearance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/15/2022
Plan of Correction
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2
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Staff 1 left the facility. The licensee will ensure all individuals subjects to a criminal record shall prior to working, residing or volunteering in a licensed facility.

Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Wei Siew Ho
LICENSING EVALUATOR NAME:Nune Margaryan
LICENSING EVALUATOR SIGNATURE:
DATE: 06/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2022


LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 06/15/2022 03:34 PM - It Cannot Be Edited


Created By: Nune Margaryan On 06/15/2022 at 02:17 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SPRINGVILLE
FACILITY NUMBER: 198603040

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above. Cleaning supplies and toxins were observed in the laundry room unlocked and accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/15/2022
Plan of Correction
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Citation cleared at the time of visit. Laundry room was locked and cleaning supplies and toxins were inaccessible to residents.
Type A
Section Cited
CCR
87303(e)(2)
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above. The water temperature was tested in a random selection of resident bathrooms. Hot water temperature measured at 122.2 degree F in bathroom #201 and in share bathroom for the rooms #202 and # 203 which is beyond the required 105 - 120 degrees which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/16/2022
Plan of Correction
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Licensee agreed to adjust hot water and will submit picture for proof.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Wei Siew Ho
LICENSING EVALUATOR NAME:Nune Margaryan
LICENSING EVALUATOR SIGNATURE:
DATE: 06/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2022


LIC809 (FAS) - (06/04)
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