Spring Garden Care Home

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Graham Gunby arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the inspection tool. LPA met with Administrator, Melisa Bot and explained the purpose of the visit. LPA and Administrator conducted a tour of the interior and exterior of the facility. Areas toured include but not limited to resident bedrooms, bathrooms, kitchen, common areas and backyard. LPA observed required furniture, and lighting throughout the residents' bedrooms and facility. LPA observed residents' bathrooms to be clean, sanitary, and in good repair. LPA observed food supplies of non-perishables for a minimum of seven (7) days and perishable foods for a minimum of two (2) days. Toxins and cleaning supplies are locked and inaccessible to residents in care. The hot water temperature was measured in the kitchen sink at 113.5 degrees Fahrenheit. LPA observed fire detectors and carbon monoxide alarms to be operable. The fire extinguishers are located in the kitchen and entry and were last serviced on 12/12/2025. LPA observed required Licensing posters posted in the entry of the facility. LPA observed medications to be locked and inaccessible to residents in care. LPA reviewed three (3) resident files. Resident files contained all required documentation. LPA reviewed two (2) staff records. Staff have all required documentation and first aid training. No deficiencies are being cited during today's inspection. Exit interview conducted and a copy of the report will be emailed to Administrator.the state’s words, verbatim · CDSS document, Feb 2, 2026

Allegation investigated: Residents sustained injuries due to staff neglect Staff left resident in soiled diapers for extended period of time

Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to deliver complaint findings into the allegation listed above. LPA met with Administrator Melisa Bot during todays inspection. During the complaint investigation LPA conducted interviews with staff, residents, and relevant parties, and conducted a file review. LPA interviewed the relevant parties in which they stated R1 had sustained injuries to their shins due to staff neglect. Relevant party stated Administrator forced R1 to remain in bed for their injuries to heal. LPA interviewed administrator in which she stated R1 utilized a sit to stand lift that assisted the resident up out of bed with staff help. Administrator stated she believes the injury on resident shins occurred when R1 placed too much pressure on their shins while getting out of the shower. Administrator believes due to R1’s skin being more fragile after a shower, that the sit to stand caused some of R1’s skin to rub off on their shins. Administrator stated she reported the injury to R1’s medical team and treatment started soon after. Administrator stated the injury did not occur from a fall or any other incident. Continuation on 9099-C. Unsubstantiated LPA reviewed resident records and administrator did not have an up to date needs and service plan reflecting new care. In addition, administrator had no documentation or notes reflecting the care being provided. Due to the information gathered LPA finds allegation to be UNSUBSTANTIATED. LPA investigated allegation, Staff left resident in soiled diapers for extended period of time". During the complaint investigation LPA interviewed residents, staff and relevant parties, and reviewed facility documentation. LPA interviewed relevant party in which they stated R1 was transferred to their wheelchair in the morning and was never changed or checked for continence care all day. LPA interviewed administrator in which she stated she changed R1 at least 4x a day or as needed. Administrator stated she or her staff have never left resident in their depend all day. LPA reviewed resident records and administrator did not have an up to date needs and service plan reflecting new care. In addition, administrator had no documentation or notes reflecting the care being provided. Due to the conflicting information, LPA finds allegation to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are unsubstantiated. Exit interview was conducted and copy of report provided.the state’s words, verbatim · CDSS document, Jan 9, 2026 · control 59-AS-20251006152247

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: Jan 30, 2026

87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirements was not met by evidenced by: Staff not meeting resident's needs which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 9, 2026

Plan of correction: Administrator agrees to take a training from an outside agency about meeting resident needs. Administrator to send into LPA a copy of training completion certificate by 1/30/26.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Bethany Mirlohi arrived to the facility to deliver complaint findings and conduct a case management visit. LPA investigated complaint and found deficiencies unrelated to complaint allegations. While investigating complaint LPA found that facility did not report incident reports into CCL or to the residents responsible party. In addition, LPA found that resident files were incomplete and missing required documents. Deficiencies cited on 809-D. Exit interview conducted and copy of report given.the state’s words, verbatim · CDSS document, Jan 9, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Jan 30, 2026

87211 Reporting Requirements. (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirements was not met by evidenced by: Incidents were not reported to CCL, responsible parties, and physicians which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 9, 2026

Plan of correction: Administrator agrees to send into CCL a statement of understanding of regulation 87211. POC due by 1/23/26.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87506(a) · Plan of correction due date: Jan 30, 2026

87506 Resident Records. (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement was not met evidenced by: Resident files were not found to be complete which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 9, 2026

Plan of correction: Administrator agrees to send into CCL a plan of how they will maintain resident files and documentation. POC due by 1/23/26.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Angela Hood arrived at the facility unannounced on 1/29/25 and met with the Administrator, Melisa Bot, to conduct a Required-1 Year Inspection. LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. There are six (6) bedrooms and four (4) bathrooms for resident use. LPA observed bedrooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition, properly maintained, and the hot water temperature was observed to be 110.1 degrees F. LPA checked the kitchen area for the ability to prepare and store food. Care home has required (2) two-day perishable and (7) seven-day non-perishable food supply on hand. LPA observed the outdoor area and perimeter of the care home to be free of clutter and debris and there appeared to be no potential safety hazards to the residents in care. Smoke detectors and carbon monoxide detector are operational. Fire extinguishers and first aid kit are maintained and ready for emergency use. LPA checked medication storage and found medications to be locked away and inaccessible to the residents. LPA reviewed three (3) resident files and also reviewed two (2) staff files. As a result of this visit, no deficiencies were cited per California Code of Regulations, Title 22. Exit interview conducted and copy of report provided.the state’s words, verbatim · CDSS document, Jan 29, 2025

Type of visit: Required - 1 Year

On 1/17/2024 at 10:30 AM, Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the inspection tool. LPA met with Administrator, Melisa Bot, and explained the purpose of the visit. At 10:35 AM, LPA and administrator toured the interior and exterior of the facility to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, residents' bedrooms, bathrooms, kitchen, garage and backyard. LPA observed required furniture, and lighting throughout the residents' bedrooms and facility. LPA observed residents' bathrooms to be clean, sanitary, and in good repair. LPA observed food supplies of non-perishables for a minimum of one (1) week and perishable foods for a minimum of two (2) days. Toxic and cleaning supplies locked and is inaccessible to residents in care. The hot water temperature was measured in the kitchen at 105 degrees Fahrenheit. First aid kit was completed. LPA observed fire detectors and carbon monoxide alarms to be operable. The fire extinguisher was last serviced on 9/27/2023. Fire drill was last conducted on 11/18/2023. LPA observed medications to be locked and inaccessible to residents in care. LPA observed required Licensing posters posted throughout the facility. At 10:50 AM, LPA reviewed a total of two (2) resident files. Resident files contain signed admission agreements, physician's reports, appraisals, identification sheets, releases, and resident's rights. Medications are centrally stored, locked, and appear to be given per doctor order. LPA compared medications to those being given for two (2) residents and found no discrepancies. Facility is correctly using the Medication Administration Records (MAR). LPA reviewed a total of two (2) staff record. Staff has training in medications, first aid and CPR, and other various areas of care provision. No deficiencies being cited during today's inspection. Exit interview conducted and report provided.the state’s words, verbatim · CDSS document, Jan 17, 2024