496800799-10-3-2023-21-AS-SHAN-CW9T7U-20231003142918

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496800799
Report Date: 10/03/2023
Date Signed: 10/03/2023 02:29:22 PM

Document Has Been Signed on 10/03/2023 02:29 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 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: 75	DATE:	10/03/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Stacy Vermeulen, Administrator		TIME COMPLETED:	02:40 PM

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License Program Analyst (LPA) Hansen arrived unannounced to conduct an annual required 1-year visit of the facility. LPA was welcomed by front desk staff. Executive Director (ED) Stacy Vermeulen arrived shortly after for the visit. There is a total of 75 assisted living residents. There is 2 residents currently on Hospice.

LPA toured the facility on 10/3/2023 at 8:35 AM with Executive Director (ED) 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 6/8/2023 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 5/31/2023. 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 3 out of 3 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 occur. Hot water temperature measured between 109.7 degrees F and 117.3 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 11 resident’s bathroom faucets while touring facility on 10/3/2023 at 9:45 AM. 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. 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.

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: 10/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023

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: 10/03/2023

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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.

A sample review of six resident records was conducted. LPA reviewed resident’s files at 12:15 PM on 10/3/2023 and learned that 6 out of 6 residents have an updated reappraisal/needs & care plan on file as well as medical assessments at this time as required by Title 22 Regulation. Medications were centrally stored in two locked medication carts in medication room at the facility. Facility has had an audit from Omnicare on 6/7/2023 and has provided a copy to the Department.

LPA initiated a file review of five personnel files but were unable to complete. LPA was also unable to review medication and will return at a later date to complete annual inspection.

No deficiencies cited during today's inspection.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023

LIC809 (FAS) - (06/04)

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