496800799-10-5-2022-21-AS-SHAN-CJWQ6P-20221005115351

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496800799
Report Date: 10/05/2022
Date Signed: 10/05/2022 11:54:05 AM

Document Has Been Signed on 10/05/2022 11:54 AM - 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 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: 81	DATE:	10/05/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Stacy Vermeulen, Administrator		TIME COMPLETED:	11:57 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	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 81 residents at the facility with no residents currently on Hospice/waiver for 6. LPA toured the facility on 10/5/2022 at 9:00 AM with Administrator Stacy Vermeulen; 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 6/1/2022 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 10/4/2022. Every resident apartment has an individual smoke detector in addition to being hard wired, and smoke detectors were found to be operational on today’s visit. LPA observed Carbon monoxide detectors to be operational during the visit as well. There are emergency lights in many of the fixtures in the common areas of the facility that come on should a power outage occur. Facility is in process of installing generator cable box in case of power outage to be used with a rental generator. Residents’ medications are centrally stored and locked in med room. Facility has a 30-day supply of medication for residents. 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 are daily activities scheduled for residents: morning exercises 6 days a week, Bocce Ball, Bingo, live music and excursions outside of facility. Continue to LIC809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/05/2022

NARRATIVE

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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. Hot water temperature measured between 109.4 degrees F and 116 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 8 of 8 resident’s bathroom faucets. An electronic water heater was purchased in 2020. 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 mitigation program plan and Infection Control plan. Posters have been placed at facility. Facility has PPE supply stored in apartment 244 and in closet under staircase. Staff had required PPE training and N95 Fit Testing.

LPA Hansen reviewed Licensing Information System (LIS) with Administrator Stacy Vermeulen who stated that it is correct and updated at this time. In addition, LPA advised facility to contact Local County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility.

In addition, facility has a designated area for visitors in the courtyard, private dining room, and in apartments. Residents also have available Facetime, Zoom, and telephone calls for visits.

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

Administrator Certificate is for Stacy Vermeulen #6059049740 Exp. 4/4/2023
All staff who do not have waivers have received COVID booster vaccinations.
LPA discussed new AB 219 LGBTQ Elder Bill of Rights with Administrator

No deficiencies cited during todays inspection

LPA Hansen is requesting Administrator to update and submit the following documents by 10/17/2022:

Continued on LIC809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2022

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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: SPRINGFIELD PLACE	FACILITY NUMBER: 496800799
	VISIT DATE: 10/05/2022

NARRATIVE

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LIC 308 Designated

LIC 309 Administrative Organization

LIC 500 Personnel Summary

LIC 610 Emergency Disaster Plan

LIC 610E-S Supplemental Emergency Disaster Plan for RCFE

LIC 9020 Register of Facility Resident’s

Copy of Control of Property

Copy of Administrator Certificate

Copy of Certificate of Liability Insurance

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2022

LIC809 (FAS) - (06/04)

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