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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800799
Report Date: 08/12/2021
Date Signed: 08/13/2021 09:22:44 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 PLACEFACILITY NUMBER:
496800799
ADMINISTRATOR:SOMMER, JESSICA JFACILITY TYPE:
740
ADDRESS:101 S ELY BLVDTELEPHONE:
(707) 769-3300
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY:112CENSUS: 69DATE:
08/12/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Stacy Vermeulen - General ManagerTIME COMPLETED:
10:30 AM
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Licensing Program Analyst's Fernandes-Goes and Hansen conducted an unannounced case management and met with Stacy Vermeulen – General Manager. The purpose of the case management visit was to obtain additional information regarding incident report that occurred on 7/27/2021 for resident R1.

LPAs interviewed Stacy V. General Manager and Kehley McKenzie – Health & Wellness Director, acquired more information and discussed regarding visitors sign in & out when residents are not allowed to be out in the community unassisted. In addition, LPAs are requesting facility written program plan on how facility will ensure that all exits are being monitor for the safety of residents that are not allowed to leave facility unassisted. Facility to submit a written plan by August 19, 2021.

The following documentation is required for a change of administrator:
LIC 200 (original - must be mailed or delivered to the Regional Office)
LIC 308 Designation of Facility responsibility (designation of who is the administrator)
Administrator Certificate
First Aid Certificate
Administrator Resume
LIC 500 Personnel Report
LIC 610 Emergency Disaster Plan for Residential Care Facilities for the Elderly
LIC 501 Personnel Record
LIC 503 Health Screening Report - personnel (keep on facility staff file to be reviewed)
TB test that shows "negative" (keep on facility staff file to be reviewed)
Copy of Board of Directors' Resolution meeting minutes signed (required for all corporations)


No deficiencies cited during today’s visit.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2021
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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