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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800799
Report Date: 10/14/2021
Date Signed: 10/14/2021 03:01:05 PM

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:VERMEULEN, STACYFACILITY TYPE:
740
ADDRESS:101 S ELY BLVDTELEPHONE:
7077693300
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY:112CENSUS: 70DATE:
10/14/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Administrator Stacy VermeulenTIME COMPLETED:
03:00 PM
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License Program Analyst (LPA) Hansen arrived unannounced to conduct an Annual Required – 1 yr. Infection Control inspection to this facility. LPA was welcomed by Stacy Vermeulen, General Manager/Administrator. There is a total of 70 residents with 1 resident currently on Hospice.

LPA arrived at the facility and had temperature checked and logged by electronic system. All staff are temperature check and logged each shift and wear masks. LPA toured the facility on 10/14/2021 at 1:30 PM with Plant Operations Supervisor Joel Bruno; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be last charged on 5/5/2021 at the time of the visit. Facility smoke detectors are hard wired and sound directly to the fire station. Smoke detectors and fire sprinklers are inspected, and inspection records are current with the last inspection being conducted on 9/1/2021. Every resident apartment has an individual smoke detector in addition to hard wired, and smoke detectors were found to be operational on today’s visit. LPA observed 2 out of 2 Carbon monoxide detectors that were found to be operational during the visit. There are emergency lights in many of the fixtures in the common areas of the facility that come on should a power outage occurs. Hot water temperature measured between 113.1 degrees F and 116.2 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 8 of 8 resident’s bathroom faucets while touring facility on 10/14/2021 at 1:50 PM. An electronic water heater was purchased in 2020. The facility has no special care plan of operation and programming for residents with Dementia. Facility serves residents without dementia. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per Title 22 Regulations. There are special provisions made for individuals with special dietary needs. Facility keeps a variety of items on the menu, and facility makes residents aware at admissions agreement of residents having the responsibility over their own special dietary needs. Food is available for residents any time of the day. There is a daily activity schedule for residents.

Continue to LIC809-C
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-1410
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/14/2021
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Toxins are stored in a locked housekeeping room. There was a supply of cleaners, hygiene products and paper products available for residents. All bathrooms designated for residents at the facility were supplied with individual paper towels and hand soap dispensers. Bathrooms in resident’s rooms have a towel and soap. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom shower. A sample tour of resident’s bedrooms was conducted, and bedrooms inspected have lighting & appropriate furnishing. Resident’s at this facility are very independent and decorate their own apartments.

Infection Control:
Facility has submitted a mitigation program plan that was approved on 4/5/2021. Posters have been placed at facility. Facility has PPE supply stored in apartment 244 and in closet under staircase. Residents’ medications are centrally stored and locked in med room. Facility has a 30-day supply of medication for residents. Some residents do wear masks inside the facility. Staff had required PPE training and N95 Fit Testing.

LPA was presented with proof of CPR & 1st Aid certification for staff.

LPA reviewed Licensing Information System (LIS) with Administrator who stated other than e-mail address that needs to be changed to SVermeulen@leisurecare.com all is correct. Disaster Drills have been conducted bi-annually with the last one being conducted 5/2021 and Fire Drills are conducted monthly. LPA advised facility to contact Sonoma County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility.




All required documents received from facility in the last few months & today

There were no deficiencies cited at this time

SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-1410
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021
LIC809 (FAS) - (06/04)
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