198603040-10-12-2023-28-AS-TVAO-CX7PEY-20231102111551

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603040
Report Date: 10/12/2023
Date Signed: 10/12/2023 11:29:26 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/03/2023 and conducted by Evaluator Mary G Flores

COMPLAINT CONTROL NUMBER: 28-AS-20230503164443

FACILITY NAME:	SPRINGVILLE		FACILITY NUMBER:	198603040
ADMINISTRATOR:	FAN, LINDA L		FACILITY TYPE:	740
ADDRESS:	12755 TORCH ST		TELEPHONE:	(626) 337-7288
CITY:	BALDWIN PARK	STATE: CA	ZIP CODE:	91706
CAPACITY:	43	CENSUS: 32	DATE:	10/12/2023
		UNANNOUNCED	TIME BEGAN:	09:04 AM
MET WITH:	Kevin Qin - Caregiver		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

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Resident sustained a fracture due to staff neglect
Staff did not seek medical attention for resident in a timely manner

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced subsequent complaint investigation visit regarding the above allegations. LPA met with Kevin Qin and explained the reason for the visit. Administrator Linda Fan arrived 10 minutes later.

The investigation consisted of the following: On 5/4/23 LPA Ramirez conducted a 24 hour health and safety check. LPA requested the following documents for Resident #1 (R1): Emergency and Information sheet, Physician’s Report dated: 4/19/21, Preplacement Appraisal, Admission Agreement, Discharge documents dated 4/3/23. On 5/4/23, Investigation Bureau Investigator, Christine Ferris was assigned the investigation. Investigator Ferris requested medical records, and conducted interviews with staff, resident. On 7/7/23, A nurse consult was submitted to the Department’s nurse consultant. On 10/12/23 LPA Flores conducted interviews with 3 staff, 3 residents, 2 family representatives and delivered findings.

(CONTINUED ON LIC 9099C)

Substantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/12/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023

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 28-AS-20230503164443

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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: SPRINGVILLE	FACILITY NUMBER: 198603040
	VISIT DATE: 10/12/2023

NARRATIVE

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The investigation revealed the following: Regarding allegations resident sustained a fracture due to staff neglect and staff did not seek medical attention for resident. It is alleged R1 sustained a fracture to the left tibia on 4/29/23 and facility did not call 911. Interviews conducted with administrator and staff revealed the following: On 4/29/23 Staff #1 (S1) assisted R1 with a shower and strapped R1 to the chair to prevent slipping. S1 wheeled R1 in the chair to R1’s bed. S1 stepped outside the room to ask Staff #2 (S2) for assistance transferring R1 to the bed but, S2 was busy at the time. S1 said they returned to the room, “became inpatient” and lifted R1 from the chair, who was still strapped to the chair. R1 was pulled back and fell down along with the chair and S1. Administrator was made aware of the fall. Family representative was contacted by administrator and informed of the fall. Per administrator they monitor R1 between 4/29/23 to 5/1/23 and did not observe bruising, swelling, or indication of pain. On 5/2/23, administrator observed swelling on R1’s left leg. An in-house x-ray was conducted, and results were texted to administrator at around 11:00pm which noted a fracture was found. X-ray Result dated 5/2/23 at 10:47pm notes: Acute fractures of the proximal tibia and fibula. On 5/3/23, R1 was sent to the hospital at around 6:00am. On 6/19/23, administrator stated S1 was aware that a two-person assist was required to transfer R1. As a result, the administrator verbally reprimanded S1. On 5/24/23, investigator attempted to interview R1 and was not able due to cognitive skills. On 5/24/23, interview conducted with S2 revealed, S2 was aware that R1 needed a two-person assist but became inpatient and decided to lift R1 alone. Physician’s report dated 4/29/21 notes R1 is motor impaired and requires continuous bed care. R1 has limited ability to communicate needs and needs assistance with most ADLs (assistance of daily living).

Based on LPAs observations, interviews conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

***An immediate Civil Penalty of $500.00 is being issued today, due to resident sustained a subdural hematoma while in care. Refer to LIC 421IM***

The issuance of a civil penalty is being considered based on Health & Safety Code 1569.49(f); if the department determines the death of the client is due to neglect.

Exit interview was conducted with Linda Fan and a copy of this report, LIC 9099D, and appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/12/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 28-AS-20230503164443

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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: SPRINGVILLE	FACILITY NUMBER: 198603040
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/12/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/13/2023 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411 Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...assistance and care as... This requirement is not met as evidence by:	1 2 3 4 5 6 7	Administrator will schedule and conduct an in-service training with all staff regarding proper transfer, and incident reporting and will submit schedule of training by POC due date 10/13/23 and copies of training log sign-in with duration of training and topic by 10/19/23.
	8 9 10 11 12 13 14	Based on document review and interviews conducted licensee did not ensure staff provided a two person assist for R1 which poses an immedicate risk to the health, safety, or personal rights to the persons in care.	8 9 10 11 12 13 14	An immediate Civil Penalty of $500.00 is being assess during this visit
Type A 10/13/2023 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities shall...:(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidence by:	1 2 3 4 5 6 7	Administrator will schedule and conduct an in-service training with all staff regarding section 87468.1. and will submit schedule of training by POC due date 10/13/23 and copies of training log sign-in with duration of training and topic by 10/19/23.
	8 9 10 11 12 13 14	Based on document review, and interviews licensee did not ensure to seek medical care in a timely manner for R1 which poses an immediate risk to the health, safety, or personal rights to the persons in care.	8 9 10 11 12 13 14

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/12/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/03/2023 and conducted by Evaluator Mary G Flores

COMPLAINT CONTROL NUMBER: 28-AS-20230503164443

FACILITY NAME:	SPRINGVILLE		FACILITY NUMBER:	198603040
ADMINISTRATOR:	FAN, LINDA L		FACILITY TYPE:	740
ADDRESS:	12755 TORCH ST		TELEPHONE:	(626) 337-7288
CITY:	BALDWIN PARK	STATE: CA	ZIP CODE:	91706
CAPACITY:	43	CENSUS: 32	DATE:	10/12/2023
		UNANNOUNCED	TIME BEGAN:	09:04 AM
MET WITH:	Kevin Qin - Caregiver		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

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Staff left resident in a soiled diaper for an extended period of time

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/12/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 28-AS-20230503164443

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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: SPRINGVILLE	FACILITY NUMBER: 198603040
	VISIT DATE: 10/12/2023

NARRATIVE

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The investigation revealed the following: Regarding allegation: Staff left resident in a soiled diaper for an extended period of time. It is alleged R1 would smell like urine because R1 wasn’t being changed. Interviews conducted on 10/12/23 revealed the following: Interviews conducted with 3 out of 3 residents revealed residents are check often, at least every two hours. Residents do not smell due to the lack of incontinence care. Interviews conducted with 3 out of 3 staff revealed residents that required assistance with incontinence are check every two hours and change as needed. One resident is changed regardless the resident is soil or not every two hours, per family request. Interviews conducted with 2 family representatives revealed facility assist with incontinence care and residents are always clean and free of odors when visiting. Facility keeps a monthly incontinence care log for the residents, staff notes initials and reason for changing upon assisting the residents.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview was conducted with Linda Fan and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/12/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 5