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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800799
Report Date: 09/01/2022
Date Signed: 09/01/2022 03:05:57 PM


Document Has Been Signed on 09/01/2022 03:05 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: 82DATE:
09/01/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Stacy Vermeulen - Administrator & Tracy Nava - Health and Wellness ManagerTIME COMPLETED:
03:10 PM
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Licensing Program Analyst (LPA) Hansen arrived unannounced to conduct a Case Management inspection and met with Administrator Stacy Vermeulen & Health and Wellness Manager (HWM) Tracy Nava. The purpose of this case management inspection is to follow up on two self reported incident reports submitted to Community Care Licensing (CCL).

LPA entered the facility and was screened at front desk with log in, COVID questions, and temperature checked.

LPA is following up regarding a self reported Incident Report received on August 29, 2022 regarding resident (R1), who was found on floor next to bed on a routine two-hour safety check. R1 was very confused and combative and was sent out to Hospital. This was R1’s second incident, first was 7/31/2022 when R1 was returning to apartment after lunch. Staff (S1) found R1 on the hallway floor unresponsive with a pump/bruise on forehead bleeding. R1 was sent to hospital.

LPA obtained documents and requested at return of R1 to facility, submit additional documentation and continue with two hour safety checks.

No deficiencies cited during this inspection.

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2022
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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