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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603040
Report Date: 10/16/2023
Date Signed: 10/20/2023 03:41:47 PM

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
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230503164443
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:
10/16/2023
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Kevin Qin - CaregiverTIME COMPLETED:
02:30 PM
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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*This is a corrected version of report created on 10/12/23 to correct information provided in the LIC 9099C*
On 10/12/23 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 2
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: 10/16/2023
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 S1 revealed, S1 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 an acute fracture 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 severe body injury of the resident 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)
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