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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603607
Report Date: 12/05/2022
Date Signed: 12/05/2022 04:59:19 PM

Document Has Been Signed on 12/05/2022 04:59 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:SPRINGFIELD MANORFACILITY NUMBER:
198603607
ADMINISTRATOR:BAIG, SHAHBAZFACILITY TYPE:
735
ADDRESS:2526 NEW AVENUETELEPHONE:
(818) 846-4469
CITY:ROSEMEADSTATE: CAZIP CODE:
91770
CAPACITY: 38CENSUS: 31DATE:
12/05/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Shahbaz Baig, ApplicantTIME COMPLETED:
01:35 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted an announced visit to the facility for the purpose of a pre-licensing evaluation. LPA met with the Administrators, Shahbaz Baig and Dominique Felbaum, who provided assistance with the tour of the physical plant. The applicant, Teodulo Bonzon was also present at the facility.

An application was submitted to CCLD for a Change of Ownership for an Adult Residential Facility. The fire clearance has been approved for a capacity of 34 Ambulatory adults only. There are currently 31 individuals residing at the facility.

LPA inspected the facility using the Pre-licensing Inspection tool and observed the following:

Structure: Facility is a one-story building which consists of 16 client bedrooms, 9 bathrooms, living room, dining room, activity room, kitchen, laundry room, and 2 detach garages. There are no pools or bodies of water at the facility. There is a shaded outdoor patio in the rear for clients to use.

Bedrooms: There are 16 bedrooms and furnishing equipped for each client - a bed, nightstand, adequate closet space, a chair, and lighting.

Bathrooms: There are a total of 9 bathrooms. There are 7 communal bathrooms and one designated for staff. Room #10 has a private bathroom.

Staff and Client files: Staff and Clients files are stored and maintained at the facility. The facility has an updated client roster and emergency contact information.

Linens & Hygiene supplies: Extra supplies of linens are observed locked in storage cabinets in the hallways. Extra hygiene supplies are stored in the office.

Appliances: All appliances in the facility are in good repair.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 12/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SPRINGFIELD MANOR
FACILITY NUMBER: 198603607
VISIT DATE: 12/05/2022
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Surveillance: The facility uses surveillance monitors in the hallways and common areas.

Emergency phone numbers, Exit Plan, and Menu: The emergency phone numbers and exit plan are posted on the bulletin board by the office. The daily menu is posted in the kitchen door.

Food service: Adequate supplies of 2-day perishable are observed. Per the Administrator, food items are purchased and restocked once a week. Food in refrigerators are properly covered to avoid contamination. The freezers were maintained at 0 degrees F.

Smoke Detectors and Fire alarm: The facility has smoke detectors in each of the client rooms, hallways, and common areas. The facility has an updated fire alarm system with carbon monoxide detection and is connected to the local fire department. The facility will conduct safety drills at least every quarter. The fire extinguishers were last inspected on 7/20/22.

Medications: Medications are stored and locked inside the rolling cart stored in the kitchen. The first aid kit contains all the required supplies along with the current first aid manual.

The following discrepancies were observed and must be corrected.
* The fire inspection indicated a clearance for 34 ambulatory adults. However, during the inspection, the additional rooms are located in a separate building that is fenced off and has a different address of 2530 New Avenue. This will require clarification due to the address for this license is at 2526 New Avenue.

* Food supplies of at least a week of non-perishable were not maintained at the facility.

LPA will return to complete the remainder of the inspection and conduct the Component III at a later date.

An exit interview was conducted. A copy of this report was given to Shahbaz Baig.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2022
LIC809 (FAS) - (06/04)
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