Wellspring Manor Senior Care

Type of visit: Required - 1 Year

On 10/04/2025, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced required – annual inspection and met with Staff Joel Morales. The facility is licensed to for (6) six non-ambulatory, of which (4) four can be bedridden. All rooms are approved for non-ambulatory and rooms #1, #2, and #3 are approved for bedridden. It has an approved hospice waiver for four (4) residents. The facility currently has one bedridden resident and it does not have any residents receiving hospice. The facility is a one-story house located in a residential neighborhood and consists of four (4) bedrooms, two (2) bathrooms, kitchen, living room/dining room, covered patio and a garage. The facility is clean. Staff accompanied LPA inside and outside the facility during this inspection. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. There are no security bars or weapons on the premises. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure... Continue to LIC809-C. shower was free of mold/mildew, a non-skid mat was in place, and hot water temperature properly measured between 114.5 degrees F. Common areas were clean and clear of hazards and doorways were free of obstructions. 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 locked. First Aid kit was available. Two fire extinguishers, last serviced April 2025, were observed in the dining room and near the restroom. Staff tested the carbon monoxide and smoke detectors in the house. Device is functional. Five (5) staff records were reviewed. Five (5) resident records were reviewed and two (2) residents’ medication was reviewed. Deficiencies are being cited according to Title 22, see LIC809-D. 1. During record review, Staff #5 (S5) was not associated to the facility. LPA Cloyd observed S5 working in the facility. S5 indicated that S5 has worked at the facility for about four days. 2. During record review, the facility did not have 20 hours of annual training hours for staff. LPA observed training records for January 2024. 3. During record review, Resident #1 - #3, and #5 did not have an annual assessment nor decline notice of an annual assessment on file. Continue to LIC809-C An exit interview was conducted, plans of correction developed, technical assistance provided, and a copy of this report with appeal rights was discussed and left with Staff Kevin Caponpon.the state’s words, verbatim · CDSS document, Oct 4, 2025

Allegation investigated: Staff left resident in soiled daipers. Staff did not safeguard resident's personal belongings. Staff did not ensure the showers were not in disrepair. Staff did not ensure resident's bed was not in disrepair. Staff did not ensure the facility had toiletries. Staff are not providing adequate food service to resident's. Staff are not meeting resident's shower needs.

On 08/29/2025 Licensing Program Analyst (LPA)Troy Watson made a subsequent complaint visit to the facility listed above and was greeted by the Care Giver Vina Simatupang. LPA explained the purpose of the visit was to deliver findings and was granted access to the facility grounds. The investigation consisted of the following: On 08/28/2025 Licensing Program Analyst (LPA) Troy Watson requested, reviewed, and obtained copies of the Staff Roster, Resident Roster, Physicians Reports, Appraisal Needs and Services and Facility Food Menu. On 08/28/2025 LPA Watson interviewed Staff #1 – Staff #3 (S1-S3) and Residents #1 – Residents #4 (R1-R4). An attempt to interview Resident #5 (R5) was made but due to dementia no interview was able to be made.LPA Watson toured the facility with the Facility Supervisor Joel Morales. CONTINUED ON LIC9099-C Unsubstantiated The Investigation revealed the following Allegation: Staff left resident in soiled diapers On 08/28/2025 LPA Watson conducted interviews with Residents #1- Residents #4 (R1-R4) and Staff #1-Staff #3 (S1-S3). An attempt to interview #5 was made, but because of dementia (R5) was not included in the outcome of the investigation. On 08/28/2025 LPA Watson interviewed Residents #1 – Residents #4 regarding the above allegation. Out of those interviewed, 4 out of 4 denied the allegation. On 08/28/2025 LPA Watson interviewed Staff #1 – Staff #3 (S1-S3). Out of those interviewed 3 out of 3 denied the allegation. LPA was told by everyone interviewed that diapers were changed regularly three or more times a day. Based on the information gathered, interviews conducted, and an analysis of records reviewed, LPA Watson found no evidence to support the allegation mentioned above. 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. Allegation: Staff did not safeguard resident's personal belongings. On 08/28/2025 LPA Watson conducted interviews with Residents #1- Residents#4 and Staff #1-Staff #3 (S1-S3). An attempt to interview #5 was made, but because of dementia (R5) was not included in the outcome of the investigation. On 08/28/2025 LPA Watson interviewed Residents #1 – Residents #4 regarding the above allegation. Out of those interviewed, 4 out of 4 denied the allegation. On 08/28/2025 LPA Watson conducted interviews with Staff #1 – Staff #3 (S1-S3). Out of those interviewed 3 out of 3 denied the allegation. LPA toured the facility and found that resident’s personal belongings were located inside their bedrooms in drawers. The Facility Supervisor Joel Morales stated that he only allowed residents to keep clothes and nothing valuable in their rooms. Every resident interviewed stated that they have never experienced any theft. Based on the information gathered, interviews conducted, and review of records LPA Watson found no evidence to support the allegation mentioned above. 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. CONTINUED ON LIC9099-C Allegation: Staff did not ensure the showers were not in disrepair. On 08/28/2025 LPA Watson conducted interviews with Residents #1- Residents#4 and Staff #1-Staff #3 (S1-S3). An attempt to interview #5 was made, but because of dementia (R5) was not included in the outcome of the investigation. On 08/28/2025 LPA Watson interviewed Residents #1 – Residents #4 regarding the above allegation. Out of those interviewed, 4 out of 4 denied the allegation. On 08/28/2025 LPA Watson conducted interviews with Staff #1 – Staff #3 (S1-S3) regarding the above allegation. Out of those interviewed 3 out of 3 denied the allegation. LPA Watson toured the facility with the Facility Supervisor Joel Morales and observed the bathroom and shower clean and in good repair. Based on the information gathered, interviews conducted, and an analysis of records reviewed, LPA Watson found no evidence to support the allegation mentioned above. 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. Allegation: Staff did not ensure residents’ bed was not in disrepair. On 08/28/2025 LPA Watson conducted interviews with Residents #1- Residents#4 and Staff #1-Staff #3 (S1-S3). An attempt to interview #5 was made, but because of dementia(R5) was not included in the outcome of the investigation. On 08/28/2025 LPA Watson interviewed Residents #1 – Residents #4 regarding the above allegation. Out of those interviewed, 4 out of 4 denied the allegation. On 08/28/2025 LPA Watson conducted interviews with Staff #1 – Staff #3 (S1-S3) regarding the above allegation. Out of those interviewed 3 out of 3 denied the allegation. LPA Watson inspected the beds in each room with the Care Giver Vina Simatupang and confirmed that each remote-controlled bed was working and in good repair. Based on the information gathered, interviews conducted, and an analysis of records reviewed, LPA Watson found no evidence to support the allegation mentioned above. 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. CONTINUED ON LIC9099-C Allegation: Staff did not ensure the facility had toiletries. On 08/28/2025 LPA Watson conducted interviews with Residents #1- Residents#4 and Staff #1-Staff #3 (S1-S3). An attempt to interview #5 was made, but because of dementia (R5) was not included in the outcome of the investigation. On 08/28/2025 LPA Watson interviewed Residents #1 – Residents #4 regarding the above allegation. Out of those interviewed, 4 out of 4 denied the allegation. On 08/28/2025 LPA Watson conducted interviews with Staff #1 – Staff #3 (S1-S3) regarding the above allegation. Out of those interviewed 3 out of 3 denied the allegation. LPA Watson toured the facility with the Facility Supervisor Joel Morales and observed the facility fully stocked and adequately supplied with toiletries. Based on the information gathered, interviews conducted, and an analysis of records reviewed, LPA Watson found no evidence to support the allegation mentioned above. 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. Allegation: Staff are not providing adequate food service to residents. On 08/28/2025 LPA Watson conducted interviews with Residents #1- Residents#4 and Staff #1-Staff #3 (S1-S3). An attempt to interview #5 was made, but because of dementia(R5) was not included in the outcome of the investigation. On 08/28/2025 LPA Watson interviewed Residents #1 – Residents #4 regarding the above allegation. Out of those interviewed, 4 out of 4 denied the allegation. On 08/28/2025 LPA Watson conducted interviews with Staff #1 – Staff #3 (S1-S3) regarding the above allegation. Out of those interviewed 3 out of 3 denied the allegation. LPA Watson requested and obtained a menu of the food served at the facility and it showed that residents were served meals three times a day. LPA observed the facility refrigerator fully stocked with various kinds of fruit, vegetables and meat. LPA Watson observed all meals served to the residents at the facility for breakfast, lunch and dinner and observed the residents being served nutritious meals. Based on the information gathered, interviews conducted, and an analysis of records reviewed, LPA Watson found no evidence to support the allegation mentioned above. 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. CONTINUED ON LIC9099-C Allegation: Staff are not meeting residents’ shower needs. On 08/28/2025 LPA Watson conducted interviews with Residents #1- Residents#4 and Staff #1-Staff #3 (S1-S3). An attempt to interview #5 was made, but because of dementia (R5) was not included in the outcome of the investigation. On 08/28/2025 LPA Watson interviewed Residents #1 – Residents #4 regarding the above allegation. Out of those interviewed, 4 out of 4 denied the allegation. On 08/28/2025 LPA Watson conducted interviews with Staff #1 – Staff #3 (S1-S3) regarding the above allegation. Out of those interviewed 3 out of 3 denied the allegation. LPA Watson conducted interviews with each resident regarding their shower needs, and the residents stated that the care givers assisted in meeting their showering needs. Based on the information gathered, interviews conducted, and an analysis of records reviewed, LPA Watson found no evidence to support the allegation mentioned above. 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 the Care Giver Vina Simatupang and a copy of this report was providedthe state’s words, verbatim · CDSS document, Aug 29, 2025 · control 11-AS-20250822100821

Type of visit: Case Management - Annual Continuation

On 09/25/24, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced annual continuation inspection and met with Supervisor Joel Morales. LPA Cloyd reviewed training records. An exit interview was conducted, technical assistance provided, and a copy of this report was discussed and left with Supervisor Joel Morales.the state’s words, verbatim · CDSS document, Sep 25, 2024

Type of visit: Required - 1 Year

On 09/20/24, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced required – annual inspection and met with Teresita “Joy” Martinez. Supervisor Joel Morales joined us later. The facility is licensed to for (6) six non-ambulatory, of which (4) four can be bedridden. Rooms #1, #2, and #3 are approved for bedridden. It is has an approved hospice waiver for four (4) residents. Annual fees are due 09/26/24. The facility is a one-story house located in a residential neighborhood and consists of four (4) bedrooms, two (2) bathrooms, kitchen, living room/dining room, covered patio and a garage. The facility is clean, sanitary, and in good repair. Staff accompanied LPA inside and outside the facility during this inspection. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. There are no security bars or weapons on the premises. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, and hot water temperature properly measured between 120F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Continue to LIC809C. Common areas were clean and clear of hazards, doorways were free of obstructions. 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 locked storage cabinet. First Aid kit was available. One fire extinguisher, last serviced April 8, 2024 was observed in the dining room. Staff tested the carbon monoxide detector in the house. Device is functional. Six (6) staff records were reviewed, 6 out of 6 staff records had the required criminal record clearances or criminal record exemptions. Five (5) resident records were reviewed and, 5 out of 5 residents records had medical assessments and pre-appraisal or needs and services plans. Two residents’ medication was reviewed. Due to insufficient time, an annual continuation is required. An exit interview was conducted and a copy of this report was discussed and left with Supervisor Joel Morales.the state’s words, verbatim · CDSS document, Sep 20, 2024

Allegation investigated: Staff handle resident in a rough manner Staff makes inappropriate comments towards resident Staff makes inappropriate comments about resident to other residents Staff makes inappropriate gestures towards resident Staff are not providing a comfortable environment for resident Resident is being threatened with an eviction

On 1/10/24, Licensing Program Analyst (LPA) Felisa Shirley conducted a subsequent complaint visit at this facility to deliver the complaint investigation findings. Upon arrival, LPA met with Joel Morales, Supervisor, who assisted with the visit. LPA explained the purpose of today's visit. The investigation consisted of the following: On 9/12/2022, LPA Montoya toured the facility with Administrator Teresita Bautista. LPA interviewed four out of four staff (S1-S4) and four out of six residents (R1-R4). LPA was unable to interview two Residents (R5-R6) due to their medical conditions. LPA requested and obtained R1’s service records (Admission Agreement, Physician’s Report, Appraisals/Needs and Services Plans, incident reports), the facility’s staff roster, resident roster, house rules/ policies, and other pertinent records. INVESTIGATIONS REVEALED THE FOLLOWING: Con'd on 9099-C Unsubstantiated Allegation: Staff handle resident in a rough manner. It is alleged that staff handle resident in a rough manner. On 9/12/2022, LPA Lourdes Montoya interviewed four out of four staff (S1-S4) and four out of six residents (R1-R4). LPA was unable to interview two Residents (R5-R6) due to their medical conditions. Based on interviews conducted, three out of four residents and four out of four staff denied that staff handled residents in a rough manner. One out of four residents claimed one staff is very rough on R1. Two out of four staff claimed R1 is rough on staff and residents. Based on records review, incident reports were submitted to the department indicating that R1 was aggressive to staff and/or residents. Based on LPA’s observations, no staff handled any resident in a rough manner. LPA observed R1 is rough to residents, staff and to the LPA. Based on information gathered, there is no sufficient evidence to corroborate the above allegation. Allegation: Staff makes inappropriate comments towards resident. It is alleged that staff makes inappropriate comments towards resident. On 9/12/2022, LPA Lourdes Montoya interviewed four out of four staff (S1-S4) and four out of six residents (R1-R4). LPA was unable to interview two Residents (R5-R6) due to their medical conditions. Based on interviews conducted, three out of four residents and four out of four staff denied that staff makes inappropriate comments towards a resident. One out of four residents claimed one staff made inappropriate comments towards R1. Two out of four staff claimed R1 is rude to staff and residents. Based on records review, incident reports were submitted to the department indicating that R1 was rude to staff and/or residents. Based on LPA’s observations, no staff made inappropriate comments towards any resident. LPA observed R1 is rude to residents, staff and to the LPA. Based on information gathered, there is no sufficient evidence to corroborate the above allegation. Allegation: Staff makes inappropriate comments about resident to other residents. It is alleged that staff makes inappropriate comments about resident to other residents. On 9/12/2022, LPA Lourdes Montoya interviewed four out of four staff (S1-S4) and four out of six residents (R1-R4). Con'd on 9099-C ). LPA was unable to interview two Residents (R5-R6) due to their medical conditions. Based on interviews conducted, three out of four residents and four out of four staff denied that staff makes inappropriate comments about resident to other residents. One out of four residents claimed all staff are talking about R1. Two out of four staff claimed R1 made comments about them to other staff that they are having inappropriate activities in the facility. Based on records review, there are no incident reports that staff are talking about R1 to other residents. Based on LPA’s observations, R1 made inappropriate comments to LPA about staff. Based on information gathered, there is no sufficient evidence to corroborate the above allegation. Allegation: Staff makes inappropriate gestures towards resident. It is alleged that staff makes inappropriate gestures towards resident. On 9/12/2022, LPA Lourdes Montoya interviewed four out of four staff (S1-S4) and four out of six residents (R1-R4). LPA was unable to interview two Residents (R5-R6) due to their medical conditions. Based on interviews conducted, three out of four residents and four out of four staff denied that staff makes inappropriate gestures towards resident. One out of four residents claimed one staff made an inappropriate act by pointing a middle finger at R1. One out of four staff claimed R1 made inappropriate acts to staff by pointing a middle finger at them. Based on records review, there are no incident reports that staff made inappropriate gestures towards any resident. LPA did not observe any staff making inappropriate gestures towards residents. LPA observed staff are polite to residents. Based on information gathered, there is no sufficient evidence to corroborate the above allegation. Allegation: Staff are not providing a comfortable environment for resident. It is alleged that staff are not providing a comfortable environment for resident. On 9/12/2022, LPA Lourdes Montoya interviewed four out of four staff (S1-S4) and four out of six residents (R1-R4). Con'd on 9099-C ). LPA was unable to interview two Residents (R5-R6) due to their medical conditions. Based on interviews conducted, three out of four residents and four out of four staff denied that staff are not providing a comfortable environment for residents. One out of four residents claimed one staff refused to assist R1 and this caused R1 to be uncomfortable. Three out of four staff claimed R1 makes staff and other residents uncomfortable by yelling at them, showing them inappropriate gestures, throwing things at them and calling them inappropriate names. Based on records review, incident reports were submitted to the department indicating that R1 was aggressive to staff and/or residents that creates the environment uncomfortable for staff and residents. There are no incident reports indicating that staff is not providing a comfortable environment for residents. LPA observed staff are quiet and LPA did not observe any behavior that would cause an uncomfortable environment to residents. LPA observed R1’s behavior and comments creating an uncomfortable environment to residents, staff and to the LPA. Based on information gathered, there is no sufficient evidence to corroborate the above allegation. Allegation: Resident is being threatened with an eviction. It is alleged that resident is being threatened with an eviction. On 9/12/2022, LPA Lourdes Montoya interviewed four out of four staff (S1-S4) and four out of six residents (R1-R4). LPA was unable to interview two Residents (R5-R6) due to their medical conditions. Based on interviews conducted, three out of four residents and four out of four staff denied that resident is being threatened with an eviction. One out of four residents claimed R1 received an eviction letter six times since last year. R1 used to read them but recently R1 just threw the eviction letters away and does not want to leave the facility. Two out of four staff revealed the facility served R1 with an eviction letter several times due to failure to follow the facility’s policies but R1 refused to leave the facility and continued to harass staff and residents. Based on records review, the facility served a 30-day eviction notice to R1 on 7/20/2022. Based on LPA’s observations, R1 was not threatened with an eviction. R1 was advised by licensee to stop violating the community’s policies if R1 desires to stay in the facility. LPA observed the licensee considered retaining R1 if R1 refrains from violating the facility’s policies. Based on information gathered, there is no sufficient evidence to corroborate the above allegation. Based on records review, interviews and observations, LPA did not find sufficient evidence to support the above allegations. Although the allegations may have happened or are 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 was conducted, and a copy of the LIC 9099 report was provided to Joel Morales, Supervisorthe state’s words, verbatim · CDSS document, Jan 10, 2024 · control 11-AS-20220906094918

Type of visit: Required - 1 Year

On 11/15/23, LPA España created an amendment to the Annual report created 11/12/23. This report serves as an Amendment to annual report created on 11/12/23. This addendum is written to clarify findings description and does not change the annual report findings recorded on 11/12/2023. Report to be signed by authorized representative. **On 11/12/2023 at 2 pm Licensing Program Analyst (LPA) David España conducted an unannounced Required-1-year annual visit. Upon arrival at the facility, LPA España conducted a risk assessment at the front door. Based on the assessment, the facility is clear of Covid-19 infection (No COVID-19 cases). LPA verified that the facility has an approved mitigation plan report. LPA was granted access and allowed to enter the facility to conduct the inspection.LPA met with Staff #1, and they toured the inside and outside grounds of the facility. The Residential Care Facilities for the Elderly (RCFE) facility is licensed for age range 60 and over, approved for (6) non-ambulatory, of which (4) can be bed-ridden, approved hospice waiver for (4), rooms #1, #2, and #3 are approved for bed ridden. LPA observed five (5) 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 140.1 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.Evaluation Report Continues on LIC 809C All mandated inspection control posters were posted. The facility has an approved Mitigation Plan Report on file with CCLD. There were deficiencies were observed during today's inspection. LPA and S#1 observed the hot water: At 2:15 PM, LPA measured the hot water temperature in bedroom bathroom #4 at 140.1 F degrees, which is not within Title 22 and poses an immediate danger to the health and safety of five (5) out of five (5) residents in care. LPA and S#1 observed ramps with potential hazards by resident room #3. 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 aid) Verification of first aid training for staff providing care, LIC9052 etc. LPA met with Staff #1 and toured the inside and outside grounds of the facility. LPA and Staff#1 did not observe PUB475 in the main entryway of the facility. LPA met with Staff #1 and did not observe annual fire drill with sign and dated plan as indicated Title 22 regulations. Advisory Notes - Technical Assistance were issued, please see LIC9102-AN. Type B deficiencies were issued, please see LIC-809D Physical Plant/Environmental Safety - Type A: 87303(e)(2) - Physical Plant/Environmental Safety - 87307(d)(4) Personnel Records/Staff Training - Type B: 87412(a) Resident Rights/Information - Technical Assistance: 87468(c)(2)(A) Disaster Preparedness - Technical Violation: 1569.695(d) An exit interview was conducted with Staff #1 and a hard copy of the report was furnished.the state’s words, verbatim · CDSS document, Nov 12, 2023

The state marks this report as 6 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.