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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603607
Report Date: 09/26/2023
Date Signed: 09/26/2023 03:43:02 PM

Document Has Been Signed on 09/26/2023 03:43 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:
09/26/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:03 PM
MET WITH:Jaem Tan - Assistant AdministratorTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mary Flores conducted a case management visit during a complaint investigation visit due to observed deficiencies.

On 9/26/23 LPA Flores conducted a complaint investigation visit. During this visit LPA reviewed admissions agreement and facility's house rules for clients #1-#3(C1-C3).
The admission agreement notes "5. eviction procedures: A.(3) ...upon thirty days written notice..., evict the client for one or more of the following reasons: Failure... to comply with... general polices... Per house rules." House Rules indicate: 8. "Alcohol, Drugs and any unprescribed medications are prohibited in the facility."
During interviews conducted with assistant administrator and clients it was revealed facility randomly tests clients for drugs. Per admission agreement reviewed and house rules, clients have not been notify in writing or consent to adhere to random drug testing. Which is a violation of the client's personal rights.

Therefore, deficiencies are being noted on LIC 809D per Title 22 Regulations.

Exit interview was conducted with Jaem Tan Assistant Administrator 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: 09/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2023
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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Document Has Been Signed on 09/26/2023 03:43 PM - It Cannot Be Edited


Created By: Mary G Flores On 09/26/2023 at 03:15 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: 09/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/27/2023
Section Cited
CCR
85068(b)(2)

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85068 Admission Agreements: (b) The admission agreement must specify the following: (2) General facility policies which are intended to ensure that no client, in the exercise of his/her personal rights, infringes upon the personal rights of any other client. This requirement is not met as evidence by:
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Administrator will submit to the department house rules or admission agreement, and plan of operation which specifies, notifies, and informs clients of random drug test to which they will agree for approval by POC due date 9/27/23.
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Based on interviews and document review licensee did not ensure clients at the facility were notify and agree to random testing in writing which poses an immediate risk to the health, safety, or personal rights to the clients in care.
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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.
SUPERVISOR'S NAME:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2023


LIC809 (FAS) - (06/04)
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