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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005361
Report Date: 11/05/2021
Date Signed: 11/05/2021 03:15:38 PM

Document Has Been Signed on 11/05/2021 03:15 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:
11/05/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:39 PM
MET WITH:Michelle Pasha and Christy ValerioTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Kimberly Lyman and Jerome Haley made an unannounced plan of correction visit to follow up on citations issued on 10/26/2021. LPAs were greeted and granted entry into the facility by Caregiver Michelle Pasha and explained the reason for the visit. House Manager Christy Valerio arrived during the visit.

At 2:45 PM, LPAs toured the facility and observed the following:

*Deficiency cited under Title 22 Regulation 87705(f)(2) pertaining to inaccessible items has been cleared. All noted items have been secured. Licensee has complied with the terms of the POC.

*Deficiency cited under Title 22 Regulation 87468.1(a)(2) pertaining to personal rights has been cleared. Facility has all posted signage during today's visit. Licensee has complied with the terms of the POC.

Advisory note dated 10/26/2021 advised the following:
  • Facility to remove eye drops from resident's room. Eye drops have been removed.
  • Facility fountain is full of green water and unsecured. Please secure fountain and ensure water is clean. Fountain is secured and clean during today's visit.
  • Tiles on the ground in side yard are loose and presenting a fall hazard. Please remove or secure tiles. Facility has not addressed issue to date.


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: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/05/2021 03:15 PM - It Cannot Be Edited


Created By: Kimberly Lyman On 11/05/2021 at 02:59 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: 11/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/19/2021
Section Cited
CCR
87303(a)

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The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirment is not being met as evidenced by:
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Licensee to secure/ repair area and forward proof to LPA by POC due date.
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Based on observation, LPAs observed noted area on advisory note dated 10/26/2021 has not been addressed. The side yard has loose tiles over a sinking part of deck presenting a fall hazard. This poses a potential health and safety risk to residents in care.
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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: 11/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/05/2021


LIC809 (FAS) - (06/04)
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