<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603040
Report Date: 02/01/2024
Date Signed: 02/01/2024 01:17:52 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
01/29/2024 and conducted by Evaluator Christine Wong
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240129081438
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: 31DATE:
02/01/2024
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Linda FanTIME COMPLETED:
01:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Illegal Eviction
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Wong conducted the “Initial 10-Day” visit to ascertain information pertaining to the above-mentioned allegation(s) and to establish the validity of the complaint. LPA met with Staff #1 Anna Dong (Manager) who allowed entry into the facility and was later met by Administrator Linda Fan who assisted with the visit.

The investigation consisted of the following: On today's date, LPA interviewed four (4) residents (R3-R6), two staff (S1-S2) and Administrator and obtained resident roster, face sheet and incident reports for R1 and R2.

See LIC 9099C for continuation
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2024
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 3
Control Number 28-AS-20240129081438
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: 02/01/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
The investigation revealed of the following: Allegation "Illegal Eviction". It was alleged that residents (R1 and R2) were discharged from hospital on 09/08/2023 and transported back to the facility via ambulances and R1 and R2 were rejected at the gate upon arrival and facility staff refused to let the ambulances in, and on 09/09/2023, family received the 30 notice from the administrator via email. LPA interviewed four residents and four out of four residents and reported staff take good care of them and they feel safe living in the facility. LPA interviewed administrator and admitted the facility was not able to handle R1 and R2 at that time due to the facility was lack of staffing and there was a COVID outbreak during that period of time. In addition, R1 still had the COVID symptoms and the facility did not have any isolation room for the residents when they come back from the hospital. Administrator also stated it was a mis-communication between hospital and residents' family as the facility is not a medical facility and facility never got any notification from hospital that residents were going to discharge from hospital and back to the facility.

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

Exit Interview Conducted and a copy of the report and appeal right was provided to the Administrator Linda Fan.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20240129081438
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: 02/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
02/15/2024
Section Cited
CCR
87224(a)
1
2
3
4
5
6
7
87224 Eviction Procedures (a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required
The requirement was not met as evidenced by
1
2
3
4
5
6
7
Administrator will ensure to follow the Title 22 regulation about Eviction and Administrator will send the plan to LPA by POC due date and state how the facility would ensure the they follow the regulation in the future.
8
9
10
11
12
13
14
LPA's interviews, the administrator admitted the facility was lack of staffing and they did not have any isolation room during that period of time and R1 was still having COVID symptoms which posed a potential risk to residents in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Christine Wong
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3