496800799-4-8-2025-21-AS-VBEI-DFKTHJ-20250409144450

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496800799
Report Date: 04/08/2025
Date Signed: 04/08/2025 01:24:36 PM

Substantiated

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
04/02/2025 and conducted by Evaluator Shannan Hansen

COMPLAINT CONTROL NUMBER: 21-AS-20250402101124

FACILITY NAME:	SPRINGFIELD PLACE		FACILITY NUMBER:	496800799
ADMINISTRATOR:	VERMEULEN, STACY		FACILITY TYPE:	740
ADDRESS:	101 S ELY BLVD		TELEPHONE:	(707) 769-3300
CITY:	PETALUMA	STATE: CA	ZIP CODE:	94954
CAPACITY:	112	CENSUS: 91	DATE:	04/08/2025
		UNANNOUNCED	TIME BEGAN:	11:10 AM
MET WITH:	Stacy Ford, Administrator		TIME COMPLETED:	01:40 PM

ALLEGATION(S):

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Staff did not make resident records available to resident's authorized representative

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced to initiate a complaint investigation and subsequently was able to deliver findings regarding the allegation listed above. LPA met with Administrator, Stacy Ford.

During investigation LPA made observations, reviewed documents and conducted interviews.
Staff did not make resident records available to resident's authorized representative- Reporting party alleges, authorized representative requested resident records on 03/20/2025 and as of 04/2/2025, no records had been produced. LPA obtained documentation on 4/4/2025 of resident records being requested on 3/20/2025 from facility by resident authorized representative and email response from facility Administrator on 3/27/2025 record request is being worked on and an update on the request will be provided by end of next week (4/4/25).

Continue on LI9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2025

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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Control Number 21-AS-20250402101124

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: SPRINGFIELD PLACE	FACILITY NUMBER: 496800799
	VISIT DATE: 04/08/2025

NARRATIVE

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Continued from LIC9099

During today’s visit, documents obtained and interview with Administrator corroborate with reporting party that on 3/20/2025 resident’s representative, requested resident records with appropriate legal confirmation indicating proof of legal representation and did not provide resident records within Title 22 Regulation 87468.2(a)(19) time frame of two (2) business days. There was sufficient information obtained to support a violation occurred. Therefore, allegation “staff did not make resident records available to resident’s authorized representative” is SUBSTANTIATED.

A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

The following deficiencies were observed (see LIC 9099D) and 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. Exit interview conducted and appeal of rights provided.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2025

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20250402101124

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: SPRINGFIELD PLACE	FACILITY NUMBER: 496800799
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/08/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/11/2025 Section Cited CCR 87468.2(a)(19)	1 2 3 4 5 6 7	87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (19) To have prompt access to review all of their records and to purchase photocopies of their records. Photocopied records shall be provided within two (2) business days and at a cost that does not exceed the community standard for photocopies. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee agrees to review regulation 87468.2 (a)(19) and submit self certification acknowledging the understanding of the regulation.
	8 9 10 11 12 13 14	Based on record review & interviews the licensee did not comply with the above regulation by not providing the requested documents to authorized representative within two (2) business days, which poses/posed a potential health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2025

LIC9099 (FAS) - (06/04)

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