WELLSPRING MANOR SENIOR CARE INC

Official classification

Type B

Official code

87463(h)

Regulation authority

CCR

What the official deficiency says

(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above for four out of five residents which poses a potential health risk to persons in care. Residents #1 - #3, and #5 did not have an annual assessment nor decline notice of an annual assessment on file.

Official plan of correction

POC Due Date: 10/20/2025 Plan of Correction The Licensee will send evidence of correction to regina.cloyd@dss.ca.gov by the POC due date.

Official classification

Type B

Official code

1569.625(b)(2)

Regulation authority

HSC

What the official deficiency says

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above for staff which poses a potential health and safety risk to persons in care. LPA observed training records for January 2024.

Official plan of correction

POC Due Date: 10/20/2025 Plan of Correction The Licensee will submit a training schedule for 2025 - 2026 to regina.cloyd@dss.ca.gov by the POC due date. The training schedule can also include the requirements for medication training.

Official classification

Type A

Official code

87355(e)(3)

Regulation authority

CCR

What the official deficiency says

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above for Staff #5 (S5) which poses a safety risk to persons in care. LPA observed S5 working in the faciliy but S5 was not associated to the facility.

Official plan of correction

POC Due Date: 10/05/2025 Plan of Correction The Licensee will ensure that all staff are associated to the facility prior to training or working. Evidence of corrections should be emailed to regina.cloyd@dss.ca.gov by the POC due date.

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview, the licensee did not comply with the section cited above. LPA's observation- LPA and S#1 observed the hot water: At 2:15 PM, LPA measured the hot water temperature in bathroom #4 at 140.1 F degrees, which is not within Title 22 regs and poses an immediate danger to the health and safety of five (5) out of five (5) residents in care..

Official plan of correction

POC Due Date: 11/13/2023 Plan of Correction The administrator shall monitor and record the hot water temp for three weeks and send the LPA the readings. The administrator shall also send to CCL a written statement that they will monitor the hot water temp. Administrator start testing the hot water and provide photo record of hot water temperature to LPA david.espana@dss.ca.gov.

Official classification

Type B

Official code

87412(a)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview and record review, the licensee did not comply with the section cited above.LPA met with Staff #1 and reviewed records of S#1, S#2, and S#3 which were missing Health Screening Report/Tuberculosis (TB) Clearance (LIC 503)-facility personnel, 1st Verification of first aid training for staff providing care, LIC9052 etc., which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/24/2023 Plan of Correction The administrator shall provide updated records for all staff members at the facility by POC date. The administrator shall also send to CCL a written statement that they will have all staff files in order and updated. Administrator will email LPA at david.espana@dss.ca.gov by POC date.

Official classification

Type B

Official code

1569.562(c)

Regulation authority

HSC

What the official deficiency says

1569.652 Termination of admission agreement upon death of resident... refund of fees paid; notice of contract termination and refunds (c) A refund of any fees paid in advance covering the time after the resident’s .. removed from the facility shall be issued... responsible for the fees or, if the deceased resident paid the fees... within 15 days after the personal property is removed. This requirement was not met as evidence by: Based on observations and interviews conducted, Licensee charged R1 a deposit fee and advance fee and did not issue a refund within 15 days This is a potential health and safety risk to clients in care.

Official plan of correction

Licensee will develop a plan on to ensure any advance paid fees according to H & S 1569.652 are refunded within 15 days after death or/personal property is removed. Proof correction must be sent to LPA by fax by 02/27/23 at 323-981-1781. *This citation was corrected during the visit when licensee refunded all fees due to POA.* Proof of correction was provided with registered mail receipt.

Deadline recorded: Feb 27, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(2)

Regulation authority

CCR

What the official deficiency says

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c). This requirement was not met as evidenced by: Based on LPA's interview with S4, he began working in this facility on 8/22/2022 on a part-time basis. S4 stated he works on Mondays and Tuesdays, 6:00 am:7:00 pm. S4 stated he is a caregiver and he provides ADL care to residents. During LPA's interview with Staff#2, S4 has a background clearance under a different facility. S2 stated he has not submitted a transfer of clearance for S4 to CCLD.

Official plan of correction

Administrator submitted a transfer of clearance (LIC 508) for Staff #4 to LPA Montoya. This deficiency is cleared on today's visit. CIVIL PENALTY ASSESSED.

Deadline recorded: Sep 13, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

(a) 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 requirement was not met as evidenced by: During LPA's tour of the facility, LPA observed the garage is cluttered with boxes, frame frame, used wheelchairs, oxygen tank and other miscellaneous items.

Official plan of correction

Administrator agreed to organize the stuff in the garage. Administrator shall send a proof of correction to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date, 9/19/2022. This is an amended report. Administrator did not have a signature on the original report.

Deadline recorded: Sep 19, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87305(a)

Regulation authority

CCR

What the official deficiency says

87305 Alterations to Existing Building or New Facilities (a) Prior to construction or alterations, all facilities shall obtain a building permit. This requirement is not met as evidenced by: On 11/12/2021, based on LPA's interviews with five staff (S1-S5), the floor tiles in the common restroom were removed and new tiles were installed. On 11/16/2021, LPA Montoya observed the restroom has new floor and wall tiles. The administrator admitted she did not inform CCLD prior to construction. This poses a potential risk to health, safety or personal rights risk to residents in care.

Official plan of correction

The licensee shall submit a letter to CCLD and explain the nature of the construction and how residents were handled to ensure their health and safety. Licensee will also review the Section on Title 22 related to this defiiciency and submit a self-certification by the POC due date to Lourdes.Montoya@dss.ca.gov.

Deadline recorded: Nov 22, 2021. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's observation, the licensee did not comply with the section cited above. The hot water temperature in the common bathroom used by residents was measured at 136.8 degrees F. This poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/12/2021 Plan of Correction Licensee shall adjust the hot water temperature and maintain between 105-120 degrees F by 8/12/2021. Licensee shall document hot temperature checks every 4 hours for one week and submit the record by 8/17/2201

Official classification

Type B

Official code

87307(d)(6)

Regulation authority

CCR

What the official deficiency says

(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's observations and photos taken, items of potential hazards are stored in outdoor walkways. LPA observed two unrolled garden hoses, pails, brooms, chairs, old cabinet, bicycle, etc.

Official plan of correction

POC Due Date: 08/18/2021 Plan of Correction Licensee shall remove all obstructions in outdoor walkways by the POC due date. Licensee shall email photos of the cleared walkway to LPA Montoya.

Official classification

Type B

Official code

87705(j)

Regulation authority

CCR

What the official deficiency says

(j) Care of Persons with Dementia: The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's observation, interview, and record review, the licensee did not comply with the section cited above. Residents #2 & #3 have memory care needs. The licensee failed to ensure auditory devices in bedroom #2 and the sliding door in the living room are operable. This poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/25/2021 Plan of Correction LPA Montoya observed the auditory devices in bedroom #2 and living room have been fixed. This was corrected on today's visit.

Official classification

Type A

Official code

1503.2

Regulation authority

HSC

What the official deficiency says

Carbon Monoxide Detectors required. Every facility licensed or certified (pursuant to this chapter) shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's observation and interview, the licensee did not comply with the section cited above. LPA did not observe a carbon monixide detector anywhere in the facility. Administrator stated there is a working detector but a staff took it off from the outlet. This poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/12/2021 Plan of Correction Licensee installed a new and operable carbon monoxide detector in the hallway near the entrance. This was corrected on today's visit.