490107656-8-21-2023-21-AS-FSAI-CUWQUX-20230821122927

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 490107656
Report Date: 08/21/2023
Date Signed: 08/21/2023 12:30:02 PM

Document Has Been Signed on 08/21/2023 12:30 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 VILLAGE		FACILITY NUMBER:	490107656
ADMINISTRATOR:	PRESSEY, JEANIE		FACILITY TYPE:	741
ADDRESS:	5555 MONTGOMERY DRIVE		TELEPHONE:	(707) 538-8400
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95409
CAPACITY:	679	CENSUS: 380	DATE:	08/21/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Health Services Director, Sharon Hobbs Back-up Administrator, Daniel Skillman		TIME COMPLETED:	12:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPAs), Farhaan Sarangi and Christi Coppo arrived unannounced at Spring Lake Village for the purpose of conducting a Required 1 year Inspection. LPAs was greeted at the door by back-up Administrator, Dan Skillman, and was granted access into the facility. Health Services Director greeted LPAs at the facility as well. LPAs and Health Services Director toured the facility. LPA observed the facility to be clean and at a comfortable temperature with all exits free from obstruction. A sample of Fire Extinguishers were found to be last charged in January of 2023 at the time of the inspection. All smoke detectors and carbon monoxide detectors sound directly to the fire station. During a tour of the facility, LPAs observed that 1 out of 7 medication carts were unlocked. LPA educated the Health Services Director on the importance of ensuring that medications are locked and inaccessible to residents in care (See LIC 9102-Technical Violation). First Aid kit was inspected and found to be appropriate during the inspection. Water temperature in a sample of 5 of 5 residents bathroom measured at 118 degrees on the first floor and 108 degrees on the second floor and is within acceptable range of 105 to 120 degrees F. There was sufficient perishable and non-perishable foods located in the kitchen. Knives and other hazardous items were locked and inaccessible to residents in care. There are special provisions made for individuals with special dietary needs. Food and Activity menu was presently available for viewing during the inspection. Cleaning products and other toxins are located on the cleaning carts which were locked and inaccessible to residents in care. There was a supply of Linens, cleaners, hygiene products and paper products available for residents in care during the inspection. All bathrooms designated for residents in the common areas at the facility were supplied with individual paper towels and hand soap. Bathrooms in resident’s rooms have a towel and soap. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. A tour of a sample of residents bedrooms were conducted, and bedrooms inspected have lighting and appropriate furnishing. (Report continued on LIC 809C)

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 08/21/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 08/21/2023

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LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + or any other infectious diseases in the facility. LPA discussed the Infection Control Plan with the Health Services Director in detail. LPAs discussed the Emergency Disaster Plan. Emergency disaster drill was last conducted on June 2023. During the discussion of the Emergency Disaster Plan, LPAs reviewed the plan and observed that Community Care Licensing (CCL) phone number was not on the document (See LIC 9102-Technical Advisory) LPA educated the Health Services Director of ensuring that CCLs number is on the Emergency Disaster Plan.

Staff files, resident files, resident interviews and staff interviews will be conducted at a later date and time. No deficiencies were cited during today's Required 1 year inspection. Exit interview was conducted and a copy of this report was given to the Health Services Director.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 08/21/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2023

LIC809 (FAS) - (06/04)

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