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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603040
Report Date: 02/01/2024
Date Signed: 02/01/2024 01:41:00 PM

Unsubstantiated


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
02/17/2023 and conducted by Evaluator Tena Herrera
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230217090050
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: 33DATE:
02/01/2024
UNANNOUNCEDTIME BEGAN:
10:08 AM
MET WITH:Linda Fan - AdministratorTIME COMPLETED:
01:50 PM
ALLEGATION(S):
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Facility refused to allow medical professional to assess resident in care.
Facility failed to meet resident's medical needs.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced subsequent complaint investigation visit regarding the above allegations. LPA met with Administrator Linda Fan and explained the reason for the visit.

The investigation consisted of the following:
During inital visit on 2/24/23 LPA Ashley Calderon obtained a copy of the resident roster interviewed Administrator and Office Manager, and the following documents were later gathered via email; Staff Roster, Resident #1 (R1) Physican Report, R1 Special Incidnet Reports (SIR's) , and Supportive Documents. LPA Calderon also toured facility. Due to insufficient information available at this time, and language barrier further investigation was required. During subsequent visit conducted today 2/1/24 LPA Herrera along with LPA Christine Wong (for translation purposes) interviewed 4 residnets and 2 staff. LPA Herrera obtained copies of staff/residnet roster, R1 Police Report and R1 Incident Reports.
(Continued on 9099-C)
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Tena Herrera
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-20230217090050
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
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The investigation revealed the following:
Allegations: "Facility refused to allow medical professional to assess resident in care" and "Facility failed to meet resident's medical needs".
It is alleged that on 2/17/23 Staff #2 (S2) refused to allow a home health nurse assess R1 for concerns of bruises, wounds and bed sores. LPA interviewed S2 (with translation assistance from LPA Wong) to ask if they recall this particular incident, S2 stated that they do not recall as this happened a long time ago and also does not remember resident, however, S2 stated that procedures during that time were more strict as the facility was still following Covid19 mandates. S2 further stated that they would only deny a home heath nurse access IF the resident is not on home health or do not have proper clearance to assess resident. S2 stated that during the date that the alleged incident took place, all visitors were required to have scheduled visits and if there was no scheduled visit staff was to schedule one for them. S2 also stated that staff assist residents with bathing needs and at any time redness, bruising, rashes or sores are observed they report it immediately. LPA Herrera reviewed R1's files and there was no documentation within file or on R1's Physician's Report indicating that resident was receiving Home Health Services, R1's family removed resident from facility on 2/20/23. During interview with S1, staff indicated that resident was not on home health or hospice and that staff are instructed to only allow visitors to access residents if authorization has been granted, from either resident, responsible party or medical professional. S1 stated they recall on 2/17/23 family and home health nurse visiting during dinner time to assess resident, due to staff being busy assisting residents with dinner it was asked to return at a later date, authorities were later called and access was granted to visit resident, both family and nurse then assessed resident, and there were no signs of bruising, wounds or bed sores found. S1 also stated that staff is trained to look for these signs while assisting residents with baths and there were no observations made by staff on bruising, wounds or beds sores for R1. LPA reviewed police report and SIR for incident dated 2/17/23 and report stated that "R1 did not appear to be suffering in any manner and appeared to be clean and well groomed". Interview with S3 (conducted by LPA Calderon during initial visit), staff denied the above allegations and stated that appointments are needed, access to residents seeking medical attention is never denied and staff provide residents with their medical needs. Interviews with 4 Residents, 4 out of 4 residents denied the above allegations and stated that they have never had facility staff refuse their medical professional to visit nor does facility staff refuse to allow residents to visit with their doctors outside of the facility and they are provided with all medical needs. (Continued on 9099-C)
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Tena Herrera
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-20230217090050
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
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Based on statements and interviews conducted with staff and residents, and review of R1's file/medical records, there was not enough supportive evidence to concur with the reported allegations.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview held, and a copy of this report will be emailed to Administrator Linda Fan.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Tena Herrera
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: 3 of 3