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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800799
Report Date: 10/05/2023
Date Signed: 10/05/2023 11:57:43 AM

Document Has Been Signed on 10/05/2023 11:57 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 PLACEFACILITY NUMBER:
496800799
ADMINISTRATOR:VERMEULEN, STACYFACILITY TYPE:
740
ADDRESS:101 S ELY BLVDTELEPHONE:
(707) 769-3300
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY: 112CENSUS: 75DATE:
10/05/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Stacy Vermeulen, AdministratorTIME COMPLETED:
12:10 PM
NARRATIVE
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License Program Analyst's (LPA) Shannan Hansen arrived at 8:30 AM to complete an unannounced annual inspection and met with Stacy Vermeulen, Administrator. There is a total of 75 residents, with 2 on hospice.

LPA conducted a sample review of five staff records at 9:00 AM on 10/5/2023 and learned that all facility staff and other individuals who require caregiver background checks have received criminal record clearances or exemptions. In addition, Direct care staff have received the additional training requirements as per Title 22 Regulations and H&S Code. LPA was presented with proof of CPR & 1st Aid certification; although 1 of 3 staff requiring 1st Aid certification was expired (see LIC809-D). Disaster Drills have been conducted quarterly in different shifts with the last one being conducted on 9/22/2023. For disaster preparedness facility has secured underground cables to connect to contracted generator placed in back of facility for fire season, 3 months out of the year. Stacy Vermeulen Administrator Certificate # 6059049740 provided proof pending.



LPA reviewed staff records, centrally stored medication record, and conducted staff interviews to complete this annual inspection.

LPA Hansen is requesting Licensee to update and submit the following documents to the SRRO by 10/22/2023:

LIC 308 Designation of Facility Responsibility

LIC 500 Personnel Record

Copy of Administrator Certificate

Proof of Liability Insurance

Continue on LIC809-C

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/05/2023
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: 10/05/2023
NARRATIVE
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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..
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/05/2023 11:57 AM - It Cannot Be Edited


Created By: Shannan Hansen On 10/05/2023 at 11:37 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: SPRINGFIELD PLACE
FACILITY NUMBER: 496800799

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)
87411(c )(1) Personnel Requirements – General All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69. Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation and record review, one out of five staff lacked required first aid certification, the licensee did not comply with the section cited above in one out of five staff which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/20/2023
Plan of Correction
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Licensee/Administrator to ensure all staff have required first aid certification training. Submit proof of staff's first aid certification by POC due date of 10/20/2023.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Bethany Moellers
LICENSING EVALUATOR NAME:Shannan Hansen
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2023


LIC809 (FAS) - (06/04)
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