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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490107656
Report Date: 08/16/2024
Date Signed: 08/16/2024 05:52:43 PM


Document Has Been Signed on 08/16/2024 05:52 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
SANTA ROSA RO, 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: 430DATE:
08/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Bill Keck-AdministratorTIME COMPLETED:
06:05 PM
NARRATIVE
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Licensing Program Analysts (LPAs), Alviso and Loera, arrived unannounced to conduct a Required-1 Year Inspection. Stationed at the front entrance of the facility there is a security guard who screens visitors upon entry; LPAs were provided a parking pass and allowed entry onto the grounds.
LPAs met with Administrator Bill Keck, Skilled Nursing Administrator Dan Skillman (back-up RCFE Administrator), and Director of Resident Health Services (RHS), Sharon Shnell-Hobbs.

Fire clearance is approved for six hundred and seventy-nine (679) may be non-ambulatory, of which two (2) may be bedridden. Hospice waiver approved for forty (40) residents. Approved delayed egress in memory care unit. Facility has a required emergency disaster plan. Facility has a required infection control plan. Last evacuation drill was held on 6/7/24, and last fire drill was 6/7/24, per review of records. LPA discussed the emergency plan regarding emergency drills, these are to be conducted quarterly per H&S Code.

LPAs reviewed five (5) resident files. All were complete. LPAs reviewed five (5) staff files. Staff had criminal record clearance as required. Staff had first aid and CPR certification as required. Staff had required training.

LPAs toured the facility grounds with RHS Sharon, memory care unit, and assisted living units.pendent units. Hot water was checked at 119.1 degrees Fahrenheit. All exits were observed to be clear of obstruction. Fire extinguishers were tagged and serviced- dated 1/9/2024. LPAs observed a sufficient supply of food. Medications were centrally stored as required, including refrigerated medications. Medications are kept in medication carts, including double locked narcotic medications. All exits doors, walkways, and breezeways had sufficient room for residents to ambulate and were found to be clear.

LPA is requesting the following documents be updated and submitted by 9/16/24.
LIC308 - Designation of Administrator Responsibility
LIC500 - Personnel Report -ensure all staff are listed/titles/days & hours working
LIC610E-Emergency Disaster Plan (ensure to review and update as needed/required)
Continued on LIC809C..
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2024
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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Document Has Been Signed on 08/16/2024 05:52 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: SPRING LAKE VILLAGE
FACILITY NUMBER: 490107656

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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LPAs observed two (2) housekeeping/cleaning carts that had numerous cleaners/disinfectants stored in them and unlocked, making them accessible to residents in care, one unsupervised cart was outside in the walkway of assisted living units, the other unsupervised cart was in an assisted living building, turned around and facing a wall., the licensee did not comply with the section cited above, which poses an immediate health, safety and/ or personal rights risk to persons
POC Due Date: 08/17/2024
Plan of Correction
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Licensee/Administrator to submit plan in how the facility will ensure that the housekeeping carts/cleaning carts are able to lock and secure cleaners/disinfectants, making them inaccessible to residents in care. Submit plan of compliance regarding the above, and follow-up with photos/receipts of purchase of locking carts, per POC follow-up date 9/6/24, , POC due date 8/17/24.
Type A
Section Cited
HSC
1569.695(f)(1)
Other Provisions
(f) A facility shall have both of the following in place: (1) An evacuation chair at each stairwell, on or before July 1, 2019.

This requirement is not met as evidenced by:
Deficient Practice Statement
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LPAs observed that two (2) stairwells out of four (4) lacked the required evacuation chair; This was the building that consists of assisted living units, and a memory care unit. LPAs observed in the additional 14 buildings, having a total of 28 stairwells; 12 of these stairwells lacked the required evacuation chair, per H&S Code., the licensee did not comply with the section cited above in [14] stairwells out of [32] stairwells. which poses an immediate health, safety and/ or personal rights risk to persons
POC Due Date: 08/17/2024
Plan of Correction
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Licensee/Administrator to submit plan in how the facility will ensure that the required evacuation chairs are put in all 14 stairwells that are currently missing the required chairs, per HSC. Submit plan of compliance with H&S Code requirements of evacuation chairs, and completion date of all evacuation chairs in place in a timely manner, per POC follow-up date of 9/6/2024 of photos and receipts of purchase, POC due date is 8/17/24.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2024
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: SPRING LAKE VILLAGE
FACILITY NUMBER: 490107656
VISIT DATE: 08/16/2024
NARRATIVE
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Infection Control Plan (ensure to review and update as needed/required)
Copy of LIC400 Handling of Client Cash Resources (include copy of surety bond if handling cash) Form must be completed by all licensees.
Copy of current Administrator Certificate

Deficiencies observed during the inspection.
LPAs observed that two (2) stairwells out of four (4) lacked the required evacuation chair; This was the building that consists of assisted living units, and a memory care unit. LPAs observed in the additional 14 buildings, having a total of 28 stairwells; 12 of these stairwells lacked the required evacuation chair, per H&S Code. This deficiency will b cited, HSC 1569.695(f)(1) Emergency Plans - An evacuation chair at each stairwell, on or before July 1, 2019, see LIC809D. LPAs obtained photos.

LPAs observed two (2) housekeeping/cleaning carts that had numerous cleaners/disinfectants stored in them and unlocked, making them accessible to residents in care, one unsupervised cart was outside in the walkway of assisted living units, the other unsupervised cart was in an assisted living building, turned around and facing a wall. This deficiency will be cited, 87309(a) Storage Space- Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients, see LIC809D. LPAs obtained photos.


Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Appeal rights provided to the Administrator.
Exit interview conducted with Administrator Bill Keck.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2024
LIC809 (FAS) - (06/04)
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