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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005361
Report Date: 10/26/2021
Date Signed: 10/26/2021 04:04:33 PM

Document Has Been Signed on 10/26/2021 04:04 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:SPRINGWELL HAVEN, LLCFACILITY NUMBER:
306005361
ADMINISTRATOR:RAMIL DE LOS SANTOSFACILITY TYPE:
740
ADDRESS:2424 FRANCISCO DRIVETELEPHONE:
(949) 524-3484
CITY:NEWPORT BEACHSTATE: CAZIP CODE:
92660
CAPACITY: 6CENSUS: 5DATE:
10/26/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Luzvimda Estrella and Christy ValerioTIME COMPLETED:
01:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and granted entry into the facility by Caregiver Luzvimda Estrella and explained the reason for the visit. Administrator Ramil De Los Santos has an administrator certificate expiring on 09/27/2022. House Manager Christy Valerio arrived during the visit.
At 11:30 AM, LPA toured the facility with Caregivers Luzvimda and Epi Estrella. Facility has 5 residents present during today's visit. LPA observed residents relaxing in the facility. All residents appeared happy and well taken care of. Facility appears clean and sanitary. All resident rooms are currently single occupancy and had the required elements as well as restrooms stocked with soap/ sanitizer. Facility screens all visitors to the facility and LPA observed the screening/ sanitizing station in the entrance of the facility. Facility utilizes a visitor sign in sheet and documents temperatures. Facility has covid precaution postings in facility but not at entrance to facility. First aid kit has all required items. Facility mitigation plan has been submitted and approved. LPA toured the outside grounds and observed multiple shaded outside visitation areas. Exit gates are unlocked and self latching. At 11:45 AM, LPA observed unsecured medication and vitamins in the unlocked caregiver room. LPA entered the unlocked garage and observed unsecured cleaning supplies such as laundry soap, raid, tile cleaner, and Ajax at 11:50 AM. LPA toured the kitchen and observed ample food supply. Residents participate in activities such as music, games, and exercise. Facility has ample supply of PPE and cleaning supplies. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation and quarantine. LPA reviewed all resident files during the visit and all files are up to date including emergency information and physician reports. All residents and staff are vaccinated for Covid-19.
LPA consulted with House Manager regarding the importance of maintaining an ample supply of emergency food and water at all times.
Based on the observations made during today's visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided as well as appeal rights.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 10/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/26/2021
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 3
Document Has Been Signed on 10/26/2021 04:04 PM - It Cannot Be Edited


Created By: Kimberly Lyman On 10/26/2021 at 12:41 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SPRINGWELL HAVEN, LLC
FACILITY NUMBER: 306005361

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/26/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
The following shall be stored inacessible to residents with Dementia:
Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed unsecured medications and vitamins in the unlocked caregiver room as well as unsecured cleaning supplies in the unlocked garage. This poses an immediate health and safety risk to persons in care.
POC Due Date: 10/27/2021
Plan of Correction
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Licensee to secure noted items and forward proof to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Alisa Ortiz
LICENSING EVALUATOR NAME:Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2021


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 10/26/2021 04:04 PM - It Cannot Be Edited


Created By: Kimberly Lyman On 10/26/2021 at 12:59 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SPRINGWELL HAVEN, LLC
FACILITY NUMBER: 306005361

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/26/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468.1(a)(2)
Personal Rights of Residents in all Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Facility does not have covid precaution/policy posted at facility entrance. LPA gave Licensee an advisory on 08/13/2021 to post signage. During today's visit there is no signage posted. This poses a potential health and personal rights risk to persons in care.
POC Due Date: 11/02/2021
Plan of Correction
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Licensee to post covid precaution/policy signage at entrance to facility and forward proof to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Alisa Ortiz
LICENSING EVALUATOR NAME:Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2021


LIC809 (FAS) - (06/04)
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