<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603607
Report Date: 10/23/2023
Date Signed: 10/23/2023 12:39:08 PM

Document Has Been Signed on 10/23/2023 12:39 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: 32CENSUS: 31DATE:
10/23/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Shahbaz Baig - AdministratorTIME COMPLETED:
12:50 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Mary Flores conducted an unannounced plan of correction visit at the facility regarding deficiencies noted on 9/26/23. LPA met with Shahbaz Baig and explained the reason of the visit.

On 9/26/23 LPA Flores conducted a case management visit to note deficiencies observed during a complaint investigation visit. The following was cited:

Section 85068(b)(2) Admission Agreement: On 9/26/23 LPA reviewed clients files and observed that the admission agreement did not notify the clients of random drug testing at the facility. House Rules do not notify about random drug test to the clients, and/or the plan of operation reviewed does not have a plan in place to randomly screen clients for drugs. Per interviews conducted with staff and clients and incident reports reviewed the facility conducted random drug test on client #1(C1). Plan of correction(POC) for the deficiency was due on 9/27/23. LPA did not received a POC for the deficiency as of 10/23/23. During this visit administrator stated, POC was faxed to the department on 9/27/23 and provided a copy of transmitting sheet which notes documents were faxed on 9/27/23.

Deficiency is cleared as of 10/23/23.

Exit interview was conducted with and a copy of this report, LIC 809D, and appeal rights were provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 10/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/23/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1