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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490107656
Report Date: 06/17/2022
Date Signed: 06/17/2022 11:28:19 AM


Document Has Been Signed on 06/17/2022 11:28 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:SPRING LAKE VILLAGEFACILITY NUMBER:
490107656
ADMINISTRATOR:PRESSEY, JEANIEFACILITY TYPE:
741
ADDRESS:5555 MONTGOMERY DRIVETELEPHONE:
(707) 538-8400
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY:679CENSUS: 31DATE:
06/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Director of Resident Health Services, Sharon Shnell-HobbsTIME COMPLETED:
11:40 AM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced to conduct a Required-1 Year Inspection. LPA met with Director of Resident Health Services, Sharon Shnell-Hobbs. This inspection was focused on the infection control practices and procedures of this facility.

Stationed at the front entrance there is a security guard who screens visitors upon entry. LPA was required to provide proof of vaccination. Visitors are given a form with the details of their screening which is to be provided to a security guard at a second screening station where visitors are given a rapid test. LPA was tested upon arrival. LPA was also provided with a KN95 mask to wear instead of a surgical mask.

LPA toured building and grounds with Director of Resident Health Services. Facility has independent living, assisted living, memory care, and skilled nursing. Facility was a comfortable temperature and in good repair. LPA observed locked medication carts as well as a central medication storage area. Toxins were observed locked and inaccessible on cleaning carts.

Assisted living had their second consecutive round of testing yesterday, everyone tested negative. This section of the facility has been under quarantine since May. Dining areas were temporarily closed but there are plans now to reopen. Residents are monitored daily and staff are required to screen before starting shift. Staff have been N95 fit tested which is conducted in house and performed yearly. LPA and director discussed infection control plan which facility plans to submit later this month.

Fire extinguishers were last inspected January 11, 2022. Facility conducted an evacuation drill on 06/16/2022.

LPA requested the following documents: LIC 610E, LIC 9020, LIC 308, Liability Insurance
No deficiencies cited during today's inspection. Exit interview conducted with Sharon Shell-Hobbs.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2022
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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