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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800799
Report Date: 12/02/2022
Date Signed: 12/02/2022 03:29:35 PM


Document Has Been Signed on 12/02/2022 03:29 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: 84DATE:
12/02/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Stacy Vermeulen - AdministratorTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Hansen arrived unannounced to conduct a Case Management inspection and met with Administrator Stacy Vermeulen. The purpose of this case management inspection is to follow up on an, SOC 341 submitted to Community Care licensing (CCL).

CCL received a SOC 341 form on 11/17/2022 reporting on 11/11/2022 staff (S1) was viewed via video provided by resident's (R1)'s family to facility, to be impatient in approach and verbal cueing while providing care to R1. Facility removed S1 from shift on 11/12/22 and was terminated from facility. R1 was on hospice and passed away on 11/16/2022 due to cancer diagnoses.

During today's inspection LPA conducted interviews, obtained records, and advised facility to submit a copy of police report when received. LPA will review information, conduct additional interviews and follow up with facility.

No citation issued during today's visit.

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 12/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2022
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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