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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603040
Report Date: 05/04/2023
Date Signed: 05/04/2023 08:25:07 PM

Document Has Been Signed on 05/04/2023 08:25 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
GREATER LA AC/SC, 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: 35DATE:
05/04/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Linda FanTIME COMPLETED:
06:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted a Case Management Deficiencies visit due to observation made while investigating complaint control # 28-AS-20230503164443 visit. The purpose of the visit was explained to Administrator Linda Fan.

During tour of facility LPA observed the following deficiencies:

· 2 bottles of prescription for R1 and R2 were observed on water dispenser machine in dining room area. This area was accessible to 35 out of 35 residents in care.

· Water temperature in 1st floor bathroom#1 was measured at 96.4 degrees F, which does not meet Title 22 regulations.

· Water temperature in 1st floor bathroom#2 was measured at 98.6 degrees F, which does not meet Title 22 regulations.

· 1st floor storage 3 was observed to accessible and contained various tools, half bag of construction material, can of paint, oxygen tank and other potentially dangerous tools.

· LPA observed several “Blood Glucose Testing and Insulin Injection Records” and “Incontinence Logs” taped outside several residents’ doors.

Deficiencies are being cited. See LIC 809-D.


Exit interview was held and a copy of this report, 809-D and appeals rights was provided via email due to printer problems.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/04/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
Document Has Been Signed on 05/04/2023 08:25 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 05/04/2023 at 04:20 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: 05/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/05/2023
Section Cited
CCR
87465(h)(1)(2)

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87465 Incidental Medical and Dental Care
(h) The following requirements shall apply to medications which are centrally stored:

(1) Medications shall be centrally stored under the following circumstances:
(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
This requirement is not met as evidenced by:
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Licensee will secure all medications and keep medications centrally stored. Licensee will retrain staff on safeguarding of medications. Licensee will send proof of re-training to LPA by POC due date via email.
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LPA observed 2 bottles of medication for R1 and R2 sitting on top of a water dispenser machine, in dinning area. Medications were accessible to 35 out of 35 residents in care.
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Type B
05/09/2023
Section Cited
CCR87303(e)(2)

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(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:
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Licensee will maintain water temperature between 105 - 120 degrees F. Licensee will develop a water log and record water temeratures every 24 hrs for the next 5 calendar days. Proof must be submitted to LPA via email.
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1st Floor shared bathroom# 1 and #2 water temperature read at 98.6 degrees F in bathroom # and 96.4 degrees F in bathroom#1.
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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:Tony Vasallo
LICENSING EVALUATOR NAME:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2023


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 05/04/2023 08:25 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 05/04/2023 at 04:43 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: 05/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/05/2023
Section Cited
CCR
87506(a)(13)(c)

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Licensing 87506
Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. (13) Continuing record of any illness, injury, or medical or dental care, when it impacts the resident's ability to function or needed services.
(c) All information and records obtained from or regarding residents shall be confidential.

This requirement is not met as evidenced by:
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Licensee will remove logs regarding care of resident immediately from resident doors. Licensee shall maintain these logs in a secure location and keep information confidential.
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At 2:29 pm LPA observed "Blood Glucose Testing and Insulin Injection Sheet" taped to the outside of R3 bedroom door and "Incontinence Log" taped to the outside of R4 bedroom door. LPA observed these logs on several residents doors throughout the facility.
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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:Tony Vasallo
LICENSING EVALUATOR NAME:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 05/04/2023 08:25 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 05/04/2023 at 05:04 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: 05/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/05/2023
Section Cited
CCR
87705(f)(1)

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87705
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia:

(1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
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Licensee will keep storage 3 and all storage doors inaccessible to dementia residents.
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During tour, LPA observed storage door 3 to be unlocked and contained various tools, paint, oxygen tank and other potiential dangerous tools.
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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:Tony Vasallo
LICENSING EVALUATOR NAME:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2023


LIC809 (FAS) - (06/04)
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