Wellspring Manor Senior Care

Allegation investigated: Resident sustained unexplained fractures while in care. Resident was left on floor for a long period of time.

Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced subsequent visit to the facility on 9/12/2023. LPA met with Administrator Joel Morales/Administrator and explained the purpose of today's visit is to deliver the complaint findings regarding the above-mentioned allegations. The investigation consisted of the following: On 09/21/20, LPA Montoya conducted a virtual 10-Day visit and toured the facility’s physical plant with Administrator Bautista. During this visit, LPA did not conduct interviews. LPA requested copies of Resident #1’s service records and other pertinent documents. A separate investigation was conducted by the Department of Social Services Investigations Bureau by Investigator Robert Kujawa. INVESTIGATION REVEALED THE FOLLOWING: Evaluation Report Continues on LIC 9099C... Unsubstantiated Allegation 1: Resident sustained unexplained fractures while in care. It is alleged that Resident #1 (R1) sustained unexplained fractures while in care. Reporting Party (RP) reported R1 was admitted to Torrance Memorial Hospital on 9/16/2020 and the x-ray result shows R1 had two broken ribs. IB Investigator Kujawa interviewed the Administrator (S1) and a Witness: R1’s family (W1). Investigator Kujawa was unsuccessful in his attempts to interview the two caregivers (S2 & S3) who were present during the incident. During the attempts by Investigator Kujawa to interview the two (2) caregivers, S2 was out of the country and S3 was no longer employed with the facility. Investigator Kujawa attempted to interview R1 (the victim); but due to medical conditions, a proper interview was not accomplished. Investigator’s interview with S1 revealed S2 witnessed R1 slide/fall out of the chair and onto the floor. S2 called S3 to assist with picking up R1 off the floor. S2 and S3 asked R1 if the resident had any pain and R1 denied pain. S1 stated both caregivers (S2 and S3) examined R1 and found no evidence of pain or injury. S1 admitted that S2 and S3 are not medical professionals and do not have medical training; but, S1 revealed that R1 was not taken to the doctor for an examination. S1 claims they did not know about R1’s fall until R1’s son notified S1 (by telephone) that R1 had suffered two (2) fractured ribs. Interview conducted of S3 by RA Ceniceros (via landline) on 08/17/23 corroborated that facility staff did not witness R1 slip and fall on 09/12/20. Based on records review, the hospital discharge summary documented that R1 was admitted to the hospital on 9/16/2020 at 13:40 hours with a diagnosis of “Fall” and “Multiple fractures of ribs of the right side”. R1’s Computed Tomography (CT) Chest Scan revealed right-sided fractures of the eighth and ninth ribs. R1 was discharged from the hospital on 09/18/2020 without any complaints. Based on records review and interviews, there is no sufficient evidence to corroborate the above-mentioned allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation of Neglect/Lack of Supervision: “Resident sustained unexplained fractures while in care” is found to be UNSUBSTANTIATED. Evaluation Report Continues on LIC 9099C... Allegation #2: Resident was left on the floor for a long period of time. It is alleged that Resident #1 (R1) was left on the floor for a long period of time. Reporting Party (RP) reported that R1 told the RP that they fell during the night on the floor and they were calling for help for a long time. Based on records review, the Unusual Incident/Injury Report indicates on 09/12/2020, R1 slipped off the chair while sitting. Both Staff (S2 and S3) picked up R1 from the floor. IB Investigator Kujawa interviewed the Administrator (S1) and a Witness: R1’s family (W1). Investigator Kujawa was unsuccessful in his attempts to interview the two (2) caregivers (S2 & S3) who were present during the incident. During these attempts by Investigator Kujawa of interviewing the two (2) caregivers, it was learned that S2 was out of the country and S3 was no longer employed with the facility. Investigator Kujawa attempted to interview R1 (the victim), but due to medical conditions, a proper interview was not accomplished. Based on Investigator Kujawa’s interview with S1 on 12/16/2020, S2 witnessed R1 slide/fall out of their chair and onto the floor, S2 called S3 for assistance to pick up R1 off the floor and place the resident onto their bed. Both S2 and S3 checked R1 and found no indication of injury or bruises. On 12/15/2020, Investigator Kujawa interviewed W1 who admitted there were no similar prior issues with the facility and the facility has been great to both for many years. W1 revealed due to R1’s medical conditions, it is difficult to understand the resident, but W1 admitted that R1 is now doing well. Interview conducted of S3 (via landline) by RA Ceniceros on 08/17/23 corroborated that facility staff had not left R1 on the floor for a long period of time following a slip and fall on 09/12/20. Based on records review and interviews, there is no sufficient evidence to corroborate that R1 was left on the floor for a long period of time. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of Neglect/Lack of Supervision: “Resident was left on the floor for a long period of time” is found to be UNSUBSTANTIATED. Exit interview conducted and a copy of the Complaint Report was issued and discussed with Licensee/Administrator Joel Morales/Administrator.the state’s words, verbatim · CDSS document, Sep 12, 2023 · control 11-AS-20200917175335

Allegation investigated: Unqualified staff accessing resident. Staff unable to locate resident’s food. Lack of supervision from staff causing resident to leave the facility.

On 07/07/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent complaint visit at this facility. LPA was greeted by caregiver Terisita Joy Maloncio. Maloncio contacted House Manger Joel Morales and explained the purpose of the visit complete the investigation. The investigation revealed the following: Interviews with staff #1-#4 (S1-S4) , resident #1- #5 (R1-R5), and witnesses #1- #2 (W1-W2). A review of (R1's) service records and other pertinent documents associated with this complaint. A review of staff and resident rosters. A tour of the facility was conducted. (Evaluation Report continues on LIC 9099-C) Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation: Unqualified staff accessing resident. The details for the complaint alleged that an unqualified staff accessed resident #1 (R1) with a mental disorder. The complainant reported (R1) was assessed by a staff working at this facility and used the information to notify the hospice's medical director who accepted the data and diagnosed (R1) with Dementia. According to the complainant, (R1) is not suffering from Dementia and is able to carry out normal activities and engage in meaningful conversations with other residents. This diagnosis is disputed by the complainant for (R1). The facility’s admission agreement for (R1) indicated on 03/29/22 was accepted for admission after being discharged from a local hospital 04/01/23. The medical discharge report did not indicate an assessment of (R1’s) mental condition. Based on a physician's report dated 03/28/22, (R1) is in fair health with no evidence of mild cognitive impairment or dementia. As a result, (R1) was later admitted under the care of Diamond Hospice Services Inc on 04/03/22 to 11/27/22. (R1) was diagnosed with Senile Degeneration of the Brain by a hospice physician. (R1) continued hospice care with Generations Hospice from 12/10/22 – 06/06/23 and was diagnosed with Alzheimer’s Disease. (R1) was discharged from Wellsprings Manor Senior Care on 06/12/23. (R1) was transferred to The Heavens at Antelope Valley on 06/08/23. A physician report dated 05/27/23 diagnosed with Dementia and resides in memory care. A review of hospice, medical, and service records revealed (R1's) family representatives had acknowledged (R1's) health condition verified with a signature. An interview hospice representative (W1) stated (R1) was given a Mental Status Examination as (R1) was previously diagnosed by Diamond Hospice with Senility on 04/03/22. (W1) stated it is likely (R1's) condition will change within eight months of switching hospices. (R1) was admitted by Generations Hospice care. Based on the information gathered, the allegation mentioned above cannot be supported. Allegation: Staff unable to locate resident’s food. The details for the complaint alleged the staff was unable to provide proper meals to resident # 1 (R1). The complainant reported on 06/11/23 (R1) did not have dinner. (R1) only soup and had leftovers and did not offer a proper meal to (R1). (Evaluation Report continues LIC 9099-C) The Department reviewed progress notes for (R1) 06/02/23 – 06/11/23 (R1) meals were noted. According to staff #2 (S2), (R1) was adamant about only eating food that (R1) had purchased. The meals prepared for (R1) were according to (R1’s) preference and followed the physician’s orders. Each meal contained some protein, grains, vegetables, fruit, and dairy. Interviews with residents #2-#3 had no issues or concerns with their meals. (R2-R3) stated they received a balanced meal three times a day with a snack. Interviews with R4 and R5 were not possible due to their health condition and unable to hold a conversation. An interview with a family member witness (W2) expressed satisfaction with the services and meals provided by staff. Based on the information gathered, there is no evidence to corroborate the allegation mentioned above. Allegation: Lack of supervision from staff causing resident to leave the facility. It is alleged due to a lack of supervision, resident #1 (R1) left the facility. The complainant stated on 06/08/23, the facility staff was unaware that (R1) left for the bank with a friend. The staff was uninformed of (R1’s) whereabouts and was away from the facility for several hours. An interview with staff #1-#2 (S1-S2) disputes this allegation. According to (S2), (R1) went out with a friend and was told by (R1) that the family representative was notified by (R1). (S2) made a call to the family representative to verify and was not able to get a hold of a family member. (R1) refused to be detained until (S2) was able to get a verification and left the facility with the friend disregarding (S2's) request to hold off. (S2) had noted this incident on (R1’s) progress notes. A review of (R1’s) physician's report dated 05/23/23, (R1) can leave the facility unassisted. Interviews with (R2-R3) had no issues or concerns for their care of supervision with any staff. (R2-R3) were complimentary of staff. Interviews with R4 and R5 were not possible due to their health condition and unable to hold a conversation. An interview with a family member witness #2 (W2) found there is no immediate health or safety concern with the resident total care at this facility. Based on the information gathered, there is no evidence to support the allegation mentioned above. Interviews could not be completed with (R1) to addressed these allegations. (Evaluation Report continues LIC 9099-C) Based on information gathered, an inspection of the facility, observation, and interviews conducted, documents reviewed, the Department found no evidence to support the allegations mentioned above. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations, did or did not occur, therefore the allegations are Unsubstantiated. An exit interview conducted with Terisita Joy Maloncio, and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jul 7, 2023 · control 11-AS-20230612150547

Allegation investigated: Staff did not issue a refund.

On 02/13/23 Licensing Program Analyst (LPA) Ernand Dabuet conducted an initial complaint investigation for the allegation listed above. LPA was greeted by house manager Joel Morales and administrator Teresita Bautista. LPA explained the purpose of today's visit is to review and audit personnel record for resident in care. The investigation consisted of record reviews. A review of the following documents: Resident roster, Staff roster, analysis of personnel records for resident #1 (R1). An nterview with house manager and licensee. An inteview with witness (W1). A tour of the facility and grounds was conducted to observe and identify any signs of neglect, abuse, or other threats to immediate health and safety. Evaluation Report continue on LIC 9099-C Substantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation: Staff did not issue a refund. It is alleged that the staff refuses to issue a refund. The complainant reported resident #1 (R1) was a former resident at this facility and was admitted on 05/10/21. However, before being admitted at Wellsprings Manor, (R1) spent a few days at Summer Breeze Manor. Both facilities are being operated by the same administrator Teresita Bautista. The complainant claimed the power of attorney (POA) to (R1) was in charge of finances for (R1) and paid every 10th of each month $3500 for rent and services. (R1) was also charged an additional deposit fee of $3500 which was paid when the contract for the Admission Agreement was approved signed and dated 04/19/21. The $3500 amount appears on a separate invoice noted as one month deposit (refunded upon termination of service). The complainant claimed (R1) passed away on 01/05/23 and the facility refused to refund the $3500 deposit and the prorated amount of $583.33 for the (5) days for rent and services in January 2023. The complainant stated this facility owes a total amount of $4083.33. According to the complainant, the (POA) was in communication with the house manager with three messages. A written statement addressed to Morales dated 01/18/23 at 12:43 pm requesting a refund. An interview with the administrator (S1) and house manager (S2) confirmed they were in communication with the (R1's) (POA) in January 2023 and the most recent text messages with (S2) on 02/09/23 and 02/11/23. (S2) responded with a text message "the office will be refunding you the deposit amount." No mention of when and if the prorated amount will be refunded on the reply message. According to (S1) the reason for the delay was due to record keeping. Since all transactions were processed through Zelle, (S1) was unsure if a deposit was charged for Summer Breeze or Wellsprings. (S1) audited the payment history for Wellsprings and did not see a deposit charged for (R1). The (POA) was requested to provide a receipt. It was claimed that neither (S1) nor (S2) intended to not refund the money, but just wanted to verify the information. Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has been met; the facility failed to refund fees paid in advance to the contractually responsible party within 15 days after the resident's death and removal of personal property as stated in Health and Safety 1569.652. Therefore, the allegation of: "Staff did not issue a refund" is found to be SUBSTANTIATED. According to the California Code of Regulations (Title 22, Division 6, Health and Safety Code), the following deficiency has been observed and citation issued (ref. LIC 9099D).the state’s words, verbatim · CDSS document, Feb 13, 2023 · control 11-AS-20230210132627

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.562(c) · Plan of correction due date: Feb 27, 2023

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.the state’s words, verbatim · CDSS document, Feb 13, 2023

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.

Type of visit: Required - 1 Year

On 11/28/2022, Licensing Program Analyst (LPA) Lourdes Montoya conducted an unannounced required annual visit with a primary focus on Infection Control measures using the new CARE Inspection Tools. LPA Montoya called Administrator Teresita Bautista and conducted a risk assessment. Based on the assessment, the facility is clear of Covid-19 infection. LPA verified that the facility has an approved mitigation plan report. LPA met with Staff Joel Morales and they toured the inside and outside grounds of the facility. The facility is licensed for six (6) non- ambulatory, of which four (4) can be bedridden; approved hospice waiver for four (4) residents. LPA observed six (6) residents and two (2) direct caregivers during the visit. During the tour, LPA did not observe bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. A comfortable temperature was maintained in the facility. There are no security bars or weapons on the premises. Resident bathrooms were checked, sufficient liquid soap and paper towels were observed. Toilets and water faucets worked properly, grab bars were secure, the shower was free of mold/mildew, and a non-skid mat was in place. The water temperature measured at 118.2 degrees Fahrenheit. A comfortable temperature was maintained in the facility. Smoke detectors are interconnected and operational. LPA observed the facility was found to be appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food supplies. The facility has (2) fire extinguishers that were charged, smoke detectors, and carbon monoxide were operable. The facility conducted a Fire/Safety Drill on 7/11/2022. A working telephone (424-263-4911) remains available. Evaluation Report Continues on LIC 809C During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for residents, staff and visitors, and sanitizing stations in common areas and restrooms. LPA observed staff were wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The facility has an approved Mitigation Plan Report on file with CCLD. No deficiencies were observed during today's inspection. An exit interview was conducted with Staff Joel Morales and a hard copy of the report was furnished.the state’s words, verbatim · CDSS document, Nov 28, 2022

Allegation investigated: Night staff did not respond to residents call for assistance.

Licensing Program Analyst (LPA) Ana Soto conducted an initial complaint investigation for the allegation listed above. Today’s complaint investigation was conducted with Joel Morales, Supervisor. The investigation consisted of following: Interviews and Record reviews. On 09/27/22, LPA Soto interviewed S#1 - S#5. R#1 - R#5, and W#1 (via telephone). LPA requested and received the following documents: Resident roster, Staff roster, R#1 file ( Face sheet, Admission agreement, ID/Emergency Information, Consent for Emergency Medical Treatment, Pre-appraisal, Physician's report (dated 05/22/20), Needs and Services Plan, Mars -August & September, 2022.) Torrance Police Report #, Pictures and video of incident dated 09/08/22 (text,) and 4 Incident reports. Unsubstantiated Based on the LPA's investigation, the investigation revealed the following. Allegation – Night staff did not respond to residents call for assistance. Interviews with staff #2 - #5 denied not responding to a bell when resident #1 requested assistance. All the staff agreed that they always respond to all the residents calls for assistance. They check on the residents 2x a night to make sure they are okay and if they might need assistance. There's one resident that needs help at least 2 to 3 times a night to go to the restroom, so they are always ready to assist any resident at any time. Sometimes the resident do not ask for assistance at night, but they still checked on them 2x a night. The staff are all live in staff and can hear the bell from any where inside the facility. Staff #1 & S#2, both agreed that R#1 needs a higher level care. R#1 refuses to let S#2 talk to R#1 doctor to see if R#1 needs new medication. R#1 has been very abusive towards S#3-S#5. R#1 has physically hit S#2 & S#3 and they refuse to press charges against R#1. There was an incident on 09/08/22, where R#1 broke a vase through on the floor and the Police was called. At that time, Police did not arrest R#1, just spoke with R#1. S#1 called the PET team for R#1, but they stated that R#1 did not meet the criteria and could to take R#1 with them. S#1 & S#2 agree that R#1 needs a higher level of care, but refuses to accept it. LPA reviewed video and pictures of the incident that occurred 09/08/22, it demonstrated R#1 yelling and picking up case and throwing the flowers and vase to the floor. Interviews with R#2, stated that care givers are great, they do a wonderful job of taking care of R#2. R#1 has to go because R#1 is always yelling at the staff and being really mean. R#1 in R#2 opinion needs be in a mental institution and requires mental medication and psychiatric help. R#1 does not belong at the facility. Interview with R#3, was not possible, R#3 was not able to communicate with LPA. Interview with R#4, R#4 refused to speak with LPA. Interview with R#5, stated that the care givers are good and R#1 has a short temper, always mad. Interview with W#1, stated that W#1 has had bad experiences with R#1, W#1 has been going to assist resident at the facility for the last six months. Every time W#1 comes across R#1, R#1 always cursing, yelling, and saying bad words to W#1. W#1 doesn't even inter-act with R#1, R#1 doesn't get assistance from W#1, but without any provocation R#1 just lashing out at W#1. W#1 tries to make sure W#1 doesn't say or do anything that will cause R#1 any agitation. LPA reviewed R#1 MARS (August and September) R#1 is not taking any medication for any mental disability. Interview with R#1, stated that all the care givers are liars and do not know what they are doing, they need to get rid of all of them. R#1 has been at the facility for 3 years and in all the time they only had one good care giver. They need to replace all the care giver and get new ones. LPA also reviewed R#1 Physician's report dated 05/22/20, it does not state any mental disability only has physical conditions. When LPA interviewed R#1, R#1 seemed frustrated and anxious and admitted to breaking the vase and throwing the flowers. Incident dated 07/07/22, 07/08/22, & 07/10/22, all state R#1 cursing and yelling at staff. The records reviewed and interviews conducted did not concur with the above allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated An exit interview was conducted with Joel Morales, Administrator, and a hard copy of report was provided.the state’s words, verbatim · CDSS document, Sep 27, 2022 · control 11-AS-20220922144101

Type of visit: Case Management - Deficiencies

This is an amended report. The administrator did not have signature on the original report. On 9/12/2022, Licensing Program Analyst (LPA) Lourdes Montoya conducted a unannounced case management - deficiency visit observed during an unrelated complaint visit. LPA met with Administrator Teresita Bautista (S1) and and three staff (S2-S4). Deficiencies: 1) 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. S4 stated he has not submitted a transfer of clearance for S4 to CCLD. 2) 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. A technical violation is used to licensee. Deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. A civil penalty of $500 was assessed. Failure to correct the deficiencies may result in additional civil penalties. Exit interview conducted and appeal rights discussed. A copy of this report and appeal rights provided to Administrator Teresita Bautista.the state’s words, verbatim · CDSS document, Sep 12, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Sep 13, 2022

(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.the state’s words, verbatim · CDSS document, Sep 12, 2022

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.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(a) · Plan of correction due date: Sep 19, 2022

(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.the state’s words, verbatim · CDSS document, Sep 12, 2022

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.

Allegation investigated: Resident sustained blood clots while in care. Resident sustained UTIs while in care. Staff yells at resident. Facility is not free of trash. Staff not smoking in designated areas.

On 11/23/2021, Licensing Program Analyst (LPA) Lourdes Montoya conducted an unannounced subsequent complaint visit at this facility. LPA met with Administrator Teresita Baustisa and explained the purpose of today's visit is to gather additional information and deliver findings for allegations mentioned above. The investigation consisted of the following: LPA inquired questions relevant to the nature of the complaint. LPA Lourdes Montoya conducted interviews with Staff (S1-S5) on 11/12/2021 and resident (R2) on 11/16/2021. LPA was unable to interview Residents (R3-R5) because R3 has mild cognitive impairment and did not want to pay attention to LPA’s questions, R4 has dementia and R5 was asleep during the visit on 11/16/2021. LPA called and interviewed a former resident (R1) on 11/17/2021. A tour of the facility’s outside grounds on 11/12/021 was conducted and both inside and outside grounds of the facility were also checked on 11/16/2021. LPA obtained residents’ (R1) service records, residents’ (R2-R5) physician’s reports; facility roster and staff roster. Report continued in LIC 9099C Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Resident (R1), the alleged victim, was admitted at Wellspring Manor Senior Care Inc on 3/1/2021. The physician’s report obtained from the facility was dated 12/8/2020. LPA obtained copies of R1’s Doctor's Clinic and hospital After Visit Summaries (AVS). The facility provided the department with two appraisals dated 3/1/2021 and 6/1/2021 which do not reflect the significant changes of R1’s medical condition during her stay in this facility. R1 was discharged from the facility on 11/10/2021. Allegation: Resident sustained blood clots while in care. It is alleged Resident sustained blood clots while in care. The complainant reported the alleged victim, Resident (R1), was observed with a lot of pain from blood clots. Based on record review of R1’s AVS dated 9/9/2021, R1 sustained a chronic deep venous thrombosis (DVT) of both legs, leg pain, right leg pain, and deconditioning. According to the review of AVS, on 11/1/2021, R1 was prescribed Enoxaparin to prevent blood clots in the leg; On 11/13/2021, R1 was admitted to Kaiser Permanente and she was diagnosed with Pulmonary Embolism upon her discharge on 11/16/2021. Interview with Staff (S1-S5) and Residents (R1-R2), they did not see symptoms that R1 has a blood clot. Staff (S1-S5) just learned that she has a blood clot when she was discharged from the hospital. Based on the information gathered, there is no evidence that staff were negligent and therefore there is no sufficient evidence to corroborate the allegation mentioned above. Allegation: Resident sustained UTI while in care. It is alleged Resident sustained Urinary Tract Infection (UTI) while in care. The complainantt reported the alleged victim, Resident (R1), was transferred to the hospital three (3) times due to UTI. Interview with Staff (S1-S4) revealed R1 sustained UTI, however, S1 stated the caregivers clean and wash R1 at least three times a day to avoid infection. Residents (R1-R2) and staff (S5) stated they have no knowledge of any residents sustaining UTI while in care. Based on review of R1’s admission agreement, she was admitted to this facility on 3/1/2021. Based on R1’s medical records, she was admitted to the hospital on 6/14/2021, 10/30/2021, and 11/13/2021 due to UTI. However, based on record review of R1’s After Visit Summary at South Bay Medical Center dated 2/23/2021 – 2/24/2021 shows R1 was provided with Patient education on Urinary Tract Report Continued in LIC 9099C Infection, no other records were attached to the summary. Record review revealed R1 has a history of UTI prior to admission at this facility. Based on the information gathered, there is no sufficient evidence to corroborate the allegation mentioned above. Allegation: Staff yells at a resident. It is alleged facility staff yells at a resident. The complainant reported there is a nurse who yells at one of the residents, they argued about everything. Based on the Department’s interview with Staff (S1-S3), a former staff (S6) had an encounter with Resident #2 who continues to yell at all staff; he calls them names, he demands them what to do in the home; he curses at them too. Staff (S1-S3) stated S6 resigned from his job because he could no longer handle the attitude of R2. S1 admitted S6 responded anxiously when R2 cursed at S6. Interview with Staff (S4-S5) and residents (R1-R2) revealed no staff yells at residents. Based on the information gathered, there is no sufficient evidence to corroborate the allegation mentioned above. Allegation: Facility is not free of trash. It is alleged facility is not free of trash. The complainant reported she observed a lot of cigarette buds around the facility. Interview with Residents (R1-R2) and Staff (S1-S5) revealed the facility is free of trash and it is clean every day. Based on LPA’s observation, the facility is clean, and no cigarette buds were observed around the outside and inside grounds of the facility. Based on the information gathered, there is no evidence to corroborate the allegation mentioned above. Allegation: Staff not smoking in designated areas. It is alleged Staff are not smoking in designated areas. The complainant reported she observed construction workers smoking too close to the facility. Record review shows the designated smoking area is the driveway area of the home or 25 feet away from the main door of the home. Interview with Residents (R1-R2) and Staff (S1-S5) revealed no staff smoke cigarettes close to the facility. S2 and S4 admitted they smoke in the designated areas. Based on LPA’s observation during her complaint visit on 11/12/2021, she observed S1 smoking in the designated area of the premises. Based on the information gathered, there is no sufficient evidence to corroborate the allegation mentioned above. REPORT CONTINUED IN LIC 9099-C Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, "Resident sustained blood clots while in care", "Resident sustained UTIs while in care", "Staff yells at resident", "Facility is not free of trash", "Staff not smoking in designated areas" did or did not occur, therefore the allegation is unsubstantiated. No deficiencies cited, Exit Interview conducted, and report given to Administrator Teresita Bautista.the state’s words, verbatim · CDSS document, Dec 2, 2021 · control 11-AS-20211102130928

Type of visit: Case Management - Deficiencies

On 11/16/2021, Licensing Program Analyst (LPA) Lourdes Montoya conducted an unannounced case management - deficiency visit. This deficiency was observed during a complaint visit at this facility on 11/12/2021. During the interview with facility staff and the administrator, it was confirmed that there was a construction in the facility. LPA observed the common bathroom floor and wall tiles were changed. Licensee failed to notify CCLD prior to the construction. A deficiency is being cited on the attached LIC 9099D. Exit interview conducted. Copy of this report and appeal rights explained.the state’s words, verbatim · CDSS document, Nov 16, 2021

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87305(a) · Plan of correction due date: Nov 22, 2021

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.the state’s words, verbatim · CDSS document, Nov 16, 2021

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.

Type of visit: Required - 1 Year

On 8/11/202, Licensing Program Analyst (LPA) Lourdes Montoya conducted an unannounced required annual visit with a primary focus on Infection Control measures using the new CARE Inspection Tools. At around 9:12 am, LPA Montoya called Administrator Teresita Bautista and conducted a risk assessment. Based on the assessment, the facility is clear of Covid-19 infection. LPA verified that the facility has an approved mitigation plan report. LPA met with Administrator Bautista and Staff Joel Morales and they toured the inside and outside grounds of the facility. The facility is licensed for six (6) non- ambulatory, of which four (4) can be bedridden; approved hospice waiver for four (4) residents. LPA observed five (5) residents and 4 staff including the administrator during the visit. During the tour, LPA observed the facility’s infection control practices. LPA did not observe a sanitizing station at the facility entrance, temperature checks and daily routine symptoms screening log of staff, residents and visitors; visitors log was observed. PPE supplies are readily available to staff, and an additional 30-day supply of PPE is stored in the garage; sufficient paper, cleaning, and disinfecting supplies were observed. The facility’s designated visitation areas are the resident’s bedroom and the back patio. LPA observed staff, residents, and visitors maintain 6 feet physical distancing, and each person wears a face covering. LPA observed required postings throughout the facility. A review of vaccination records was conducted; four (4) out of five (5) residents and all five (5) staff have been vaccinated with Covid-19. None of the staff have completed the N-95 fit testing. Per Staff Joel Morales, the facility staff received an Infection Prevention and Control training from the Department of Public Health in January 2021. Two (2) out of five (5) residents have memory care needs. Potentially dangerous items, including sanitizers, are kept inaccessible to residents with dementia. LPA observed the auditory devices in resident bedroom #2 and the sliding door in the living are not operable. REPORT CONTINUED IN LIC 809C All rooms were inspected. Beds in shared bedrooms are 6 feet apart/3 feet head-to-toe apart. Beds and bedding supplies were in good condition, adequate lighting provided, storage for resident personal belongings was observed. LPA observed a fruit fly in the resident bedroom #1. There are no security bars or weapons on the premises. Resident bathrooms were checked, sufficient liquid soap and paper towels were observed. Toilets and water faucets worked properly, grab bars were secure, the shower was free of mold/mildew, and a non-skid mat was in place. The water temperature measured at 136.8 degrees F. A comfortable temperature was maintained in the facility. Smoke detectors are interconnected and operational. LPA did not observe a carbon monoxide detector anywhere in the facility. LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives and toxins were kept in a locked storage cabinet. LPA observed about about five to seven fruit flies in the kitchen. Centrally stored medications were observed stored in their originally received containers and kept safe and locked and inaccessible to clients in care. The First Aid kit was available. Two fire extinguishers last serviced on 4/12/2021 were observed in the dining area and the hallway near the bedrooms/bathroom. Outside grounds were toured, and no bodies of water were observed. LPA observed potential hazards obstructing the walkways such as unrolled garden hoses, an old cabinet, cleaning supplies (brooms and pails) chairs, bicycle, etc. Advisory Notes were issued, and Technical Assistance was provided. Deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted and appeal rights discussed. A copy of this report and appeal rights provided to Staff Joel Morales.the state’s words, verbatim · CDSS document, Aug 11, 2021