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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 490107656
Report Date: 02/07/2025
Date Signed: 02/07/2025 10:57:18 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
01/30/2025 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20250130111931
FACILITY NAME:SPRING LAKE VILLAGEFACILITY NUMBER:
490107656
ADMINISTRATOR:KECK, WILLIAMFACILITY TYPE:
741
ADDRESS:5555 MONTGOMERY DRIVETELEPHONE:
(707) 538-8400
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY:679CENSUS: 357DATE:
02/07/2025
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Bill KeckTIME COMPLETED:
11:30 AM
ALLEGATION(S):
1
2
3
4
5
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7
8
9
Staff did not ensure facility was kept free of mold
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst Leibert arrived unannounced for the purpose of investigating this complaint. LPA met with the Administrator and privately with the residents of the apartment which is the subject of this complaint. The following determinations are made: An anonymous Complainant has alleged that staff have not ensured that facility is free from mold; Resident (R1) first noticed possible mold in apartment, located in the independent section of the facility, and notified management on 1/26/2025; Management responded on 1/27 with a maintenance team and remediation group assessed the situation and determined there was mold in the bathroom and laundry room of the apartment; repairs were began immediately; R1 states that the facility management responded to R1's report quickly and that there has been ongoing repairs made to the areas where mold was found; R1 has stated satisfaction with the facility's response and indicates the response was timely. Based upon observations and statements, this complaint is UNFOUNDED, meaning that it is false or without a reasonable basis. Complaint is DISMISSED.
Report left. No citations issued today.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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