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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800799
Report Date: 08/18/2021
Date Signed: 08/18/2021 03:17:13 PM

Document Has Been Signed on 08/18/2021 03:17 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:SPRINGFIELD PLACEFACILITY NUMBER:
496800799
ADMINISTRATOR:SOMMER, JESSICA JFACILITY TYPE:
740
ADDRESS:101 S ELY BLVDTELEPHONE:
(707) 769-3300
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY: 112CENSUS: 68DATE:
08/18/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Stacy Vermeulen - General Manager & Kehley McKenzie HWD via phoneTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Hansen & Fernandes-Goes conducted an unannounced case management – incident and met with Stacy Vermeulen - General Manager & via phone Kehley McKenzie - Health & Wellness Director. The purpose of the case management visit was to obtain additional information regarding recent incident report that was self-reported by the facility.

LPAs obtained more information on SIR submitted to CCL on 8/11/2021 that occurred on 8/8/2021 regarding resident R1 incident report medication error. Facility staff S1 dispensed medication Norco 10MG-325MG tablets on 8/8/21 and gave resident R1 2 tablets at 12:38 AM. Per doctors orders on file dated 8/3/2021, Norco 10MG-325MG take 1 tablet by mouth every 12 hours as needed for pain. Facility uses an electronic MARs (Medication Administration Records) to track and allow med techs to follow doctor's orders. According with lead med tech Ermi interview staff will have a red target on electronic MARs if trying to give a medication in the wrong time or quantity. Staff S1 didn't follow doctor's orders when resident R1 requested 2 Norco by dispensing 2 Norcos at once. (see copies on file, LIC 809-D) Facility is conducting medication training including shadowing lead med tech, and will be assessing staff S1 before allowing to return as med tech.

In addition, LPAs requested training and records for staff med tech S1, and learned that staff S1 was hired on 12/4/2020. Facility wasn't able to provide proof of initial medication training due to change of leadership in the facility per general manager Stacy V. and Kehley - Health & Wellness Director. (see staff records on file, LIC 809-D)

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided. Appeal of Rights Given.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 08/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/18/2021
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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Document Has Been Signed on 08/18/2021 03:17 PM - It Cannot Be Edited


Created By: Shannan Hansen On 08/18/2021 at 11:27 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: SPRINGFIELD PLACE
FACILITY NUMBER: 496800799

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/18/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/19/2021
Section Cited
CCR
87465(a)(c)(2)

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87465(a)(c)(2)Incidental Medical & Dental Care Services.Once ordered by the physicias the medication is given according to the physician's directions. This requirement isn’t met as evidenced by:Based on staff interview & incident report submitted to CCL on 8/11/2021 facility staff didn't comply w/section cite above by given resident R1 meds as
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Facility to ensure that med techs will follow doctor's orders when dispensing medications. Facility to provide CCL with plan for S1 training by POC date of 8/19/21. In addition, facility to complete all training planned for staff S1 and submit topics, time, and dates to CCL by 9/1/2021 before allowing staff S1
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ordered/prescribed by the Physician which poses an immediate health & safety risk to resident in care. LPAs learned that staff S1 dispensed medication Norco 2 10-325 tablets instead of only 1 every 12 hrs per doctor's orders dated 8/3/21 on file to R1 on 8/8/2021. (see copies on file)
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dispensing medications alone.
Type B
09/01/2021
Section Cited
HSC1569.69

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H&S 1569.69 Employees assisting residents with self-administration of medication; training requirements.This requirement is not met as evidenced by:Based on file review & interviews, facility didn't comply w/section cite above in 1 out of 1 initial med tech staff training records not on file which poses a potential health, safety, and personal rights
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Facility to ensure that all staff at facility has required trainings on file according with their position. Facility to submit proof of initial training for staff S1 with dates, time, trainer according with Health & Safety Code by POC due date of 9/1/2021 in order to clear this citation.
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risk to residents in care. LPAs requested records of training for staff med tech S1 during visit and were informed that facility has no proof of training on facility file for staff S1 at this time. Staff S1 was hired on 12/4/2020 according with staff file. There is no medication and shadowing proof of initialor continuing training on file.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Kimberley Mota
LICENSING EVALUATOR NAME:Shannan Hansen
LICENSING EVALUATOR SIGNATURE:
DATE: 08/18/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2021


LIC809 (FAS) - (06/04)
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