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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490107656
Report Date: 07/16/2021
Date Signed: 07/16/2021 11:29:51 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:SPRING LAKE VILLAGEFACILITY NUMBER:
490107656
ADMINISTRATOR:CATALDO, MICHAELFACILITY TYPE:
741
ADDRESS:5555 MONTGOMERY DRIVETELEPHONE:
(707) 538-8400
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY:679CENSUS: 33DATE:
07/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Director of Resident Health Services, Sharon Shnell-HobbsTIME COMPLETED:
11:45 AM
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Licensing Program Analysts (LPA) Erik Gonzalez Campos and Victoria Willis conducted an unannounced Required – 1 Year inspection and were greeted by reception. LPAs met with director of resident health care services, Sharon Shnell-Hobbs There are currently 24 residents in assisted living and 9 in memory care.

LPAs toured assisted living and memory care beginning at 9:00 AM. The facility was found to be clean and a comfortable temperature. There was an ample supply of linens, cleaners, hygiene products and paper products available for residents. Toxins were inspected and are located in locked housekeeping carts as well as in closets throughout the building. LPAs observed the necessary personal protective equipment (PPE) to support a resident in isolation. All bedrooms are private therefore residents could isolate in their own bedroom if necessary. Resident's bathrooms contain necessary grab bars and non-slip floors/mats. Hand sanitizer was observed in resident bedrooms and throughout the facility. Medication is centrally stored in locked cabinets. Bedrooms are equipped with lighting and proper bedding that is clean and in good repair.

Staff were observed to be wearing KN95 masks. Staff confirmed they were N95 fit tested as well as having been given infection control training by local public health. Facility has a 100 percent vaccination rate for staff/residents in assisted living/memory care and has therefore discontinued surveillance testing. LPAs observed caution tape on doors in assisted living/memory care. It was explained that this was a precautionary measure to dissuade staff/residents from other parts of the facility passing through to the other side of the facility. Caution tape does not prevent residents in assisted living from exiting building. Residents are screened daily for COVID symptoms.

Mitigation plan was reviewed and signed during visit. Due to new guidance LPA requested facility update mitigation plan regarding visitation.

Continued on LIC 809C
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2021
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
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: SPRING LAKE VILLAGE
FACILITY NUMBER: 490107656
VISIT DATE: 07/16/2021
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Current visitation policy is to have visitors screened and sign in by security at the main entrance. Upon arrival to the facility LPAs were waved in without screening. LPAs were not screened until entering assisted living/memory care. This was discussed with Sharon Shnell-Hobbs and guidance was provided to be diligent about screening.

Fire extinguishers were last inspected January 20, 2021. Facility has current emergency disaster plan. Last emergency drill was conducted on July 12, 2021.

No deficiencies cited during this inspection
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2021
LIC809 (FAS) - (06/04)
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