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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490107656
Report Date: 08/29/2023
Date Signed: 08/29/2023 03:50:09 PM

Document Has Been Signed on 08/29/2023 03:50 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: 380DATE:
08/29/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Health Services Director, Sharon Hobbs
Back-up Administrator, Daniel Skillman
RN Supervisor, Thai Waanasna
TIME COMPLETED:
04:00 PM
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Licensing Program Analysts (LPAs), Farhaan Sarangi and Christi Coppo arrived unannounced at Spring Lake Village for the purpose of conducting a Case Management-Annual Continuation. 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 were directed to the RN Supervisor.

During the Case Management-Annual Continuation, LPAs reviewed 5 of 5 staff files and found those files to be appropriate during the inspection. LPAs reviewed the Medication Orders and found those to be appropriate during the inspection. LPA reviewed resident records and found those to be appropriate during the inspection. LPAs interviewed 5 of 5 residents in care and 5 of 5 staff members in care. First Aid Certificates were not available for viewing (See LIC 9102-Technical Advisory). LPA advised facility to send a copy of ALL First Aid/CPR cards to the LPA. LPA requested the following documents to be sent:

LIC 500-Personnel Report
LIC 308-Designation of Responsibility
LIC 400- Affidavit regarding Client Cash Resources
Liability insurance
Control of Property
Resident Roster
First Aid Certificates for 5 staff members

No deficiencies were cited during today's Case Management-Annual Continuation. Exit interview was conducted and a copy of this report was given to the Health Services Director.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 08/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2023
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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