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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005361
Report Date: 10/07/2024
Date Signed: 10/07/2024 10:19:40 AM

Document Has Been Signed on 10/07/2024 10:19 AM - 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/
DIRECTOR:		RAMIL DE LOS SANTOSFACILITY TYPE:
740
ADDRESS:2424 FRANCISCO DRIVETELEPHONE:
(949) 524-3484
CITY:NEWPORT BEACHSTATE: CAZIP CODE:
92660
CAPACITY: 6CENSUS: 6DATE:
10/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:14 AM
MET WITH:Cristy ValerioTIME VISIT/
INSPECTION COMPLETED:
10:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit to Springwell Haven. The purpose of today’s visit was to conduct the Annual Required inspection. LPA was allowed entry into the facility and explained the reason for the visit. Facility is licensed for 6 non-ambulatory residents. Facility has an approved hospice waiver for 3 residents and the home currently has 1 resident on hospice. Administrator Cristy Valerio arrived during the visit. Upon entry, LPA observed two residents medications on the dining room table unsecured.
LPA Lyman along with Caregiver Nenita Hernandez toured the facility at 7:30 AM. LPA toured the physical plant, checked food service, first aid kit and reviewed records. The home consists of five resident bedrooms, 2 common restrooms, 1 resident restroom, caregiver room, staff room, living room, dining room, and kitchen. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident rooms are single and double occupancy. At 7:40 AM, LPA observed Resident 3 (R3) has bed rails at head and foot of bed. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 105.2 and 118 degrees F in all facility bathrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards. First aid kit had all the elements including thermometer, tweezers and scissors. LPA observed toxins are secured during today's visit. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. At 7:45 AM, LPA observed unsecured medications in the unlocked caregiver room. Smoke detectors and carbon monoxide detectors tested operational during today's visit. Fire extinguishers are fully charged. Kitchen appliances are operational during today's visit. LPA toured the outside grounds and there are no safety concerns noted. Exit gates are unlocked and operational. LPA observed ample emergency food and water. Facility does not have proof of required quarterly emergency drills. LPA reviewed the emergency disaster plan and infection control and plans are thorough and complete.
CONTINUED ON LIC 809C DATED 10/07/2024.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 10/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/07/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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, LLC
FACILITY NUMBER: 306005361
VISIT DATE: 10/07/2024
NARRATIVE
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Facility provides activities in the form of exercise, and music therapy. LPA reviewed six resident files and three staff files. Resident files contained required documents including admission agreements, physician reports and resident appraisals. Staff files reviewed contained required documentation of medical clearance/ TB, CPR training and criminal record clearance as well as required training. LPA reviewed medication storage and administration. LPA observed facility staff are checking R1's blood sugar. Medications are stored in a locked cabinet. Medications are being administered per physician order.

Based on the observations made during today's visit, the following violations are being cited per California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted and a copy of this report as well as appeal rights were discussed and provided with facility representative.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 10/07/2024 10:19 AM - It Cannot Be Edited


Created By: Kimberly Lyman On 10/07/2024 at 09:34 AM
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: 10/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on interview, the licensee did not comply with the section cited above. Facility has not conducted emergency drill which poses an immediate health and safety risk to persons in care.
POC Due Date: 10/08/2024
Plan of Correction
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Licensee to conduct emergency drill and forward proof to LPA by POC due date.
Type A
Section Cited
CCR
87628(a)
he licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by an appropriately skilled professional.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. Facility staff are performing blood glucose checks which poses an immediate health and safety risk to persons in care.
POC Due Date: 10/08/2024
Plan of Correction
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Facility to submit a plan to discontinue checking blood glucose and forward proof to LPA by POC due date.
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: 10/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 10/07/2024 10:19 AM - It Cannot Be Edited


Created By: Kimberly Lyman On 10/07/2024 at 09:34 AM
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: 10/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(5)(A)
Postural Supports
(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on observation, the licensee did not comply with the section cited above. R3 has two bed rails on bed, at the head and foot of bed, which poses a potential health and safety risk to persons in care.
POC Due Date: 10/21/2024
Plan of Correction
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Licensee removed rails during visit. CLEARED.
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: 10/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2024


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 10/07/2024 10:19 AM - It Cannot Be Edited


Created By: Kimberly Lyman On 10/07/2024 at 09:43 AM
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: 10/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(H)(2)
Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.


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 multiple medications unsecured which poses an immediate health and safety risk to persons in care.
POC Due Date: 10/08/2024
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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4
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: 10/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2024


LIC809 (FAS) - (06/04)
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