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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490107656
Report Date: 07/25/2023
Date Signed: 07/25/2023 03:00:13 PM


Document Has Been Signed on 07/25/2023 03:00 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
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: 440DATE:
07/25/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Executive Director, Jeanie PresseyTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Spring Lake Village for the purpose of conducting a Case Management-Incident Inspection. LPA was greeted at the door by Executive Director, Jeanie Pressey and was granted access into the facility.

During this Case Management-Incident Inspection, LPA reviewed Resident #1's file. LPA interviewed Resident in care.

No deficiencies were observed or cited during today's Case Management-Incident Inspection. Exit interview was conducted and a copy of this report was given to the Executive Director.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:
DATE: 07/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2023
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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