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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 490107656
Report Date: 06/24/2022
Date Signed: 06/24/2022 10:36:51 AM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/21/2022 and conducted by Evaluator Erik Gonzalez Campos
COMPLAINT CONTROL NUMBER: 21-AS-20220621142438
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:
06/24/2022
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Skilled Nursing Administrator, Dan SkillmanTIME COMPLETED:
10:45 AM
ALLEGATION(S):
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Facility is not allowing indoor visitations
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unnanounced to open a complaint investigation regarding the above allegation. LPA met with Skilled Nursing Administrator, Dan Skillman.

There is an allegation that facility is not allowing indoor visitations. Upon entering the facility LPA was screened for COVID and required to perform a rapid test before being granted access indoors. LPA conducted interviews and toured the facility. Per Dan Skillman current policy is to require visitors to test before entering. Unvaccinated visitors are not being allowed to visit indoors even with a negative COVID test. Facility has reported cases of COVID to Community Care Licensing since 04/29/2022. Per interview assisted living/memory care had their second round of negative testing on 6/16/2022, prior to this, this section of the facility had been under quarantine guidelines as directed by local public health (LPH).

Continued on LIC 9099C
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 21-AS-20220621142438
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 VILLAGE
FACILITY NUMBER: 490107656
VISIT DATE: 06/24/2022
NARRATIVE
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LPA conducted a phone interview with LPH during inspection. Interview revealed that facility has been following visitation guidelines which are stricter than PIN 22-07 as directed to them by LPH due to the outbreak. Based upon the interviews and observations this complaint is UNFOUNDED, meaning that it is not true and/or, has no reasonable basis. The allegation is DISMISSED.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2