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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800799
Report Date: 08/16/2022
Date Signed: 08/16/2022 03:27:32 PM

Document Has Been Signed on 08/16/2022 03:27 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:SPRINGFIELD PLACEFACILITY NUMBER:
496800799
ADMINISTRATOR:VERMEULEN, STACYFACILITY TYPE:
740
ADDRESS:101 S ELY BLVDTELEPHONE:
(707) 769-3300
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY: 112CENSUS: 81DATE:
08/16/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Stacy Vermeulen, AdministratorTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Hansen conducted an unannounced case management and met with Administrator Stacy Vermeulen. The purpose of this case management inspection is to following up on a self reported incident report, SOC 341, submitted to Community Care Licensing (CCL).

CCL received a self report incident report and SOC341 form on 7/13/2022 reporting on 7/5/2022 resident's (R1) family member notified facility R1 was missing $50 dollars from wallet (kept in night stand) and R1 also informed there was an additional $400 dollars missing from tea box in R1's kitchen cabinet. Administrator conducted internal investigation and obtained statements. Submitted reports cross reported to Petaluma Police Department and responsible party notified. LPA made copies of internal investigation notes, records, conducted interviews and made observations. Administrator agrees to inform LPA when investigation is complete and how facility is going to proceed regarding second incident of alleged stolen monies.

There has not been any other like incident's in the facility since.


No deficiencies cited during today's inspection.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2022
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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