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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603607
Report Date: 11/17/2025
Date Signed: 11/17/2025 04:44:18 PM

Document Has Been Signed on 11/17/2025 04:44 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/
DIRECTOR:		BAIG, SHAHBAZFACILITY TYPE:
735
ADDRESS:2526 NEW AVENUETELEPHONE:
(626) 572-4146
CITY:ROSEMEADSTATE: CAZIP CODE:
91770
CAPACITY: 32CENSUS: 31DATE:
11/17/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:17 AM
MET WITH:Shahbaz Biag, Administrator and Christopher Ignacio Assistant AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:48 AM
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Licensing Program Analyst (LPA) Alberto Lopez conducted the required annual inspection. LPA met with Shabaz Baiz (Administrator) and discussed the purpose of today’s visit. Christopher Ignacio (Assistant Administrator) assisted with this visit.

This home is approved for (31) ambulatory clients. This home consists of (16) shared bedrooms, (9) bathrooms, dining area, kitchen, laundry room, activities room and a staff office.

LPA observed the following:

Infection Control: Facility has an Infection Control plan in place.

Operational Requirements: Staff are adhering to operational requirements.

Physical Plant & Environment Safety: Smoke alarms and carbon monoxide detectors tested and operable. Fire extinguishers appear to be full and are located throughout the facility premises. Last fire drill was conducted on 09/22/2025. LPA inspected 6 random rooms. The following bathrooms were inspected, and hot water temperature was measured between 117.5 -128.5 which is not within range of 105.0 -120.0 degrees F. Knives, cleaning solutions, and disinfectants are locked and inaccessible to clients.

Refer to LIC 809C for the continuation of this report.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 11/17/2025
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(continued from 809B)
Staffing: There is sufficient staffing at the facility. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.

Personnel Records-Training: LPA reviewed staff files for Staff #1 (S-1) and Staff #4 (S-4). Staff have current First Aid/CPR certification. Staff have Health Screening and Tuberculosis screening

Client Rights-Information: Client rights are posted and were also observed in client files.

Client Records-Incident Reports: LPA reviewed Client files for Client #1 (C-1) through Client #5 (C-5). Client files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Weight Record, Functional Capabilities Assessment, Consent for Medical Treatment, House Rules, Appraisal Needs and Services Plan, and Client Rights were observed. Clients 60 and over were missing the Residential care for the Elderly (RCFE) LIC602A

Food Service: There are sufficient food supplies of 2-day perishable and (1) week of non-perishable items. The food is properly stored in the refrigerator. Additional food supply is stored inside the garage. Cleaning supplies are kept away from the food preparation areas. The kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept clean and stored properly.

Health Related Services: The medications are centrally stored and locked inside the kitchen in a locked medication cart. Medications are administered as prescribed by the Physician.

Incidental Medical Services: Per staff, there are (0) clients with a restrictive health plan, (0) client utilizing postural supports and (0) clients with prohibited health conditions.

Disaster Preparedness: The facility has an Emergency Disaster Plan in place but needs updating.

Deficiency cited and technical violations provided. Exit interview, appeals rights and a copy of this report were provided to Shabaz Baig (Administrator).

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2025
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 11/17/2025 04:44 PM - It Cannot Be Edited


Created By: Alberto Lopez On 11/17/2025 at 04:32 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SPRINGFIELD MANOR
FACILITY NUMBER: 198603607

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above water temperature 117.5 - 128.4 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/18/2025
Plan of Correction
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Administrator will adjust water temperature and keep log for 3 days and send to LPA as POC.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lisa Hicks
NAME OF LICENSING PROGRAM MANAGER:
Alberto Lopez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2025


LIC809 (FAS) - (06/04)
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