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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496800799
Report Date: 01/25/2021
Date Signed: 01/25/2021 04:06:26 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/18/2020 and conducted by Evaluator Carla Fernandes-Goes
COMPLAINT CONTROL NUMBER: 21-AS-20201118155737
FACILITY NAME:SPRINGFIELD PLACEFACILITY NUMBER:
496800799
ADMINISTRATOR:SOMMER, JESSICA JFACILITY TYPE:
740
ADDRESS:101 S ELY BLVDTELEPHONE:
(707) 769-3300
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY:112CENSUS: 66DATE:
01/25/2021
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Johnathan Thomas - General ManagerTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Residents were solicited by staff to donate money.
INVESTIGATION FINDINGS:
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The Department conducted a complaint investigation regarding the allegation listed above. Licensing Program Analyst (LPA) Fernandes-Goes made contact on this date, by phone, and conducted an unannounced visit with General Manager - Johnathan Thomas, for the purpose of close the complaint due to COVID-19 precautions.

On 11/25/2020 at 1:30 PM, LPA Fernandes-Goes conducted an interview, and requested documentation. During documentation review, and interview with Johnathan Thomas – General Manager on 11/25/2020 and 4 residents on 1/25/2021, LPA learned that facility has a committee of residents who every November distributes a letter to residents at the facility requesting voluntary donations for an “Annual Fund Raiser … to express their gratitude to all our workers who serve us day and night throughout the year”. (copy on file) In addition, facility Office Procedures revised on 4/2018 states facility policy as “employees are NOT permitted to accept tips … however; once a year … during the end-of-the-year holiday season.”
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 21-AS-20201118155737
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: SPRINGFIELD PLACE
FACILITY NUMBER: 496800799
VISIT DATE: 01/25/2021
NARRATIVE
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This agency has investigated the complaint alleging "Residents were solicited by staff to donate money.” We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.

No deficiencies cited during this inspection.
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2