An Ontario care center is under state orders to admit no new clients after inspectors found conditions that put current patients at “risk of immediate jeopardy.”
The state Department of Human Services imposed the restriction on Nov. 22 for Dorian Place, 375 N. Dorian Dr. in Ontario. That was the second time in two months the state concluded the assisted care facility was violating numerous state regulations governing care.
The state agency also ordered improvements in operations at Dorian Place’s sister facility three blocks away. Wellsprings, 2104 W. Idaho Ave. in Ontario, faces state conditions imposed on Oct 8.
Dorian Place is licensed for 50 clients and Wellsprings for 38, according to state officials.
Kind Care, a Connecticut company, manages both assisted living facilities.
Daniel Evans, a company vice president, in an interview on Friday, Nov. 29, disputed that Dorian Place patients were at risk.
“The residents are very, very happy with Dorian Place,” Evans said.
“We are working very diligently very, very closely with the state.”
–Daniel Evans, Kind Care vice president
Evans said he couldn’t discuss state allegations until Kind Care finished its own investigation at both facilities. He said he didn’t know who owns the businesses that hired Kind Care to manage the Ontario operations. He said he would ask other Kind Care executives for that information.
State records show Dorian Place was licensed in 2020 and changed owners in May 2023 to a company called Dorian Business LLC, which has no publicly listed telephone or website. Wellsprings was acquired in May 2023 by Wellsprings Business LLC, which also has no publicly listed telephone or website.
Evans said Kind Care is bringing in a new executive director for Dorian Place. Consultants have been retained at both facilities.
“We are working very diligently very, very closely with the state,” Evans said.
He said he conducted a town hall-style meeting with residents recently “to go over changes coming.”
He said, for example, that silverware has been updated, new placemats added and light bulbs replaced in the dining room.
State records released to the Enterprise show the state agency inspected the facilities in September as part of a change in ownership.
Within days of the inspection, the state issued an order documenting 14 violations at Dorian Place and 13 at Wellspring.
The second inspection of Dorian Place led to the ban on new admissions. The facility had to post signs at every exit door announcing the ban. The facility also was ordered to provide minimum staffing at all hours.
“The residents of the facility are at risk of immediate jeopardy” according to the Nov. 22 order. It said that Dorian Place’s violations result in “a threat to the health, safety and welfare of its residents.”
According to the state order’s most recent order, Dorian Place failed to “provide qualified awake direct care staff in sufficient number to meet the 24-hour scheduled and unscheduled needs of each resident.”
Inspectors found the facility failed to determine the competency of 11 out of 12 caregivers, the order said.
“This has been corrected,” Evans said on Monday, Dec. 2.
In the October order, the state found that Dorian Place “failed to investigate injuries of unknown cause” to two patients and didn’t report the cases to the state when “abuse and neglect could not be ruled out.”
The assisted care facility didn’t have required plans for four residents that reflected “the residents’ care needs, provided clear direction to staff and updated at least quarterly,” the October order said.
A registered nurse didn’t assess two patients after two residents “experienced a significant change of condition” and Dorian Place “failed to ensure they had established and maintained infection prevention and control protocols to provide a safe, sanitary and comfortable environment.”
For two patients, the order found, Dorian Place didn’t have written physician orders for medications and treatments.
The state has previously fined Dorian Place for violating state rules.
The facility was fined $375 after the state found Dorian Place failed in October 2023 to make medication available to a patient “causing unreasonable discomfort” and “is considered neglect of care and constitutes abuse,” according to state records.
Another $1,250 fine was issued after the state found that Dorian Place didn’t reorder a patient’s insulin, leaving the patient “without their insulin from approximately two days” in February 2024.”
The October order for Wellsprings found shortcomings as well.
That included failing to investigate “incidents and injuries of unknown cause” involving one patient, inadequate care plans for two residents and no assessment by a registered nurse of a “significant change” in two patients.
The facility was fined $188 for not providing a safe environment in November 2023 after a resident “left the facility without assistance in inclement weather causing unreasonable discomfort.”
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