Spring Lake Village

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Coppo conducted an unannounced annual required inspection and met with Executive Director/Administrator Ferdinand Buot and Director of Resident Health Services (RHS), Sharon Shnell-Hobbs. There are currently 24 residents in Assisted Living and 6 in Memory Care. At this time there are no residents receiving hospice services. The facility has an approved hospice waiver for 40 residents. At approximately 9:30am LPA, Administrator (Admin), Executive Chef (EC), and Director of Maintenance (DM) toured building and grounds. Kitchen is located in the independent living area (IL), and an ancillary kitchen in the assisted living area (AL: Laurel Place). The Montgomery Center includes a pool, gym and locker rooms. The pool is secured and entry is made with a FOB system. Storage and janitor closets were inspected and contained an ample supply cleaners, hygiene and paper products. Toxins were stored in the janitor closet and inaccessible to residents. Required postings observed. All pathways free from obstruction. LPA toured kitchen with EC. LPA observed completed refrigerator and freezer temperature logs. Logs complete and temperatures observed were with regulation. Food is prepared in the IL kitchen. Food was found to be stored in a safe manner with the amount of fresh and non-perishable foods within regulation. Menu including dietary restrictions was observed. First aid kit was complete, except a for pair of tweezers. EC will replace. Water temperature in sinks measured at 130.2 degrees F. Admin immediately put up signs indicating water temperature over 125 degrees F. Fire extinguishers were last serviced 12/12/25. Fire drill last completed 6/5/26. Smoke/Carbon Monoxide/Sprinklers are hardwired and serviced by vendor. Last date of service was 7/17/26. All systems Continued on 809C... Continued from 809... pass except for the fire panel. Per report from vendor, fire panel not communicating with central monitoring. Fire watch was recommended as first responders would not be notified if alarms were engaged. DOM advised LPA that company did isolate the cause of the disconnection and it was repaired as of 7/24/26. LPA observed completed work order for repair. Facility has three (3) vehicles for resident use. Fire extinguishers and First Aid kits present. LPA observed emergency lights, food, and water supply. Water temperature accessible to AL residents in care measured at 116.9 degrees F in the Art Room, which is within regulation between 105 and 120 degrees F. At approximately 1:00pm LPA reviewed 10 resident files. All files complete. At approximately 1:30pm LPA reviewed 10 staff files. LPA reviewed staff training records. All staff providing care to residents are trained to administer medications. LPA went over Health and Safety Codes (HSC) 1569.625, 1569.69, and 1569.696 and advised of subject matter requirements for hands-on medication training. LPA also went over subject matters required per 1569.696. LPA advised that all staff must have First Aid training completed, but only one per shift is required to be CPR certified. LPA advised that all training hours must be current based on employee's hire date. At approximately 3:00pm LPA and Director of Resident Health Services (RHS), Sharon Shnell-Hobbs toured Assisted Living (AL). Water temperatures read 107.5 degrees F in room #201, 116.9 degrees F in room #207, 110.7 degrees F in room #210, 115.2 degrees F in room #104, all of which are within regulation between 105 and 120 degrees F. Evacuation chairs observed at each stairwell. At approximately 4:00pm LPA did a spot check of medication and medication records. LPA advised that all residents that are able to administer their own medications should have those medications in a secured box/area. LPA advised that facility must have current signed doctors' orders on file and they should match what is listed on the Centrally Stored Medication Log (CSML) including PRNs. LPA went over PRN MAR requirements. LPA advised that all current prescribed medications, prescription and PRNs Continued on 809C(2)... Continued from 809C... both, must be logged on the CSML. Everything should match, if an order is discontinued the discontinuation order stored in the residents file. No deficiencies cited during this inspection. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: LIC500- Personnel Report LIC308- Designation of Responsibility Liability Insurance Exit interview conducted with RHS and a copy of this report was given.the state’s words, verbatim · CDSS document, Aug 20, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Coppo conducted an unannounced annual required inspection and met with Executive Director/Administrator Ferdinand Buot and Director of Resident Health Services (RHS), Sharon Shnell-Hobbs. There are currently 24 residents in Assisted Living and 6 in Memory Care. At this time there are no residents receiving hospice services. The facility has an approved hospice waiver for 40 residents. LPA and RHS toured the buildings and grounds of the Memory Care (MC) Unit. MC has a total of 11 units. Facility has 4 approved delayed egress doors in MC. LPA observed doors to be in working order. Fire extinguishers present, last serviced 12/6/25. LPA and RHS toured MC kitchen, activity room, and rooms #110, #111, #118, and #113. MC kitchen is not utilized to prepare food. All meals are catered from main kitchen and delivered via insulated containers. Range/stove in MC has induction heat. All sharps locked. Water temperatures in sinks measured 114.6 degrees F in room #110, 114.9 degrees F in room #111, 110.7 degrees F in room #118, 113.2 degrees F in room #113, and 110.9 degrees F in the common bathroom located in the activity room, which are all within the required 105-120 degrees F. LPA and RHS discussed adding a pull cord to common bathroom. Room #118 had a non-skid mat present but is showing black film and black spots. All other rooms toured need a non-skid mat or non-skid strips added to the shower. RHS advised LPA she will have maintenance replace and add them immediately. LPA will return at at later date to complete annual inspection. No deficiencies cited. Exit interview conducted with RHS and a copy of this report given.the state’s words, verbatim · CDSS document, Aug 11, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA), Cuadra arrived unannounced at Spring Lake Village for the purpose of conducting a Case Management-Incident visit to follow up on SOC341 suspected adult/elder physical abuse. LPA met with with Dan Skillman Health Care Administrator and Director of Resident Health Services (RHS), Sharon Shnell-Hobbs.. During this Case Management-Incident Inspection, LPA learned that this incident happened in the Skilled Nursing Unit, where Licensing does not have jurisdiction in this part of the facility, but LPA confirmed that the responsible parties including law enforcement case #SR250010503, Ombudsman and CDPH were cross reported. LPA also followed up on a SOC341 submitted to CCL on 10/01/25. However, this incident is involving two residents from independent living section of the Spring Lake Village. No deficiencies were observed or cited during today's Case Management-Incident visit. Exit interview was conducted and a copy of this report was given to the Administrator.the state’s words, verbatim · CDSS document, Oct 2, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Cuadra conducted an unannounced annual required inspection and met with Executive Director/Administrator William "Bill" Keck and Director of Resident Health Services (RHS), Sharon Shnell-Hobbs. At the front entrance of the facility there is a security guard who screens visitors upon entry; LPA was provided a parking pass and allowed entry onto the grounds. There are currently 25 residents in Assisted Living and 7 in Memory Care. Some residents are receiving hospice services. The facility has an approved hospice waiver for 40 residents. The facility has an approved fire clearance for 679 who may be non-ambulatory, of which two (2) may be bedridden. Approved delayed egress in memory care unit. LPA/RHS toured the buildings and grounds of this 679 bed Continuing Care Retirement Community, kitchen is located in the independent living area (IL), assisted living area (AL: Laurel Place), memory care (MC), Montgomery Center includes a pool, gym and locker rooms. The pool is secured and entry is made with a FOB system. Ten resident's bedrooms were equipped with lighting and furnished per regulation. Storage and Janitor closets were inspected and contained an ample supply cleaners, hygiene and paper products. Toxins were stored in the janitor closet and inaccessible to residents. Housekeeping carts were observed in hallways locked and secured. Food is primarily prepared in the IL kitchen. Food was found to be stored in a safe manner with the amount of fresh and non-perishable foods within regulation. Menu including dietary restrictions were observed. Activity calendar and complete first aid kit was observed. Required postings observed. Continued on 809-C... Continued from LIC809... Fire extinguishers were located throughout the facility and in kitchens with a charge date of January 2025. Facility is equipped with a fire pull system and sprinkler system. Smoke detectors are hard wired. Last certification of fire system was conducted on 7/11/25. Exit doors in the MC unit have a delayed egress which was functional. There are three generators available. Emergency lights and food was available for emergencies. Emergency drills are conducted quarterly on each shift in AL and MC with the last one being completed 6/2025. Evacuation chairs observed at each stairwell. Water temperature measured 112.8, 115.7, 116.8, 117.1, 112.1, 116.3, 115.4 and 117.3 degrees F which is within regulation between 105 and 120 degrees F in faucets used by residents. All resident's bathrooms contained necessary grab bars and non-slip floors/mats. Medications are stored in two medication carts per unit for a total of four medication carts which were locked and secured. LPA reviewed 9 staff and 10 resident's files. 5 out of 9 staff do not have 1st aid/CPR certificates current (technical violation was issued), but they do have required additional training 20 hours complete. Residents have medical assessments and care plans updated. Administrator certificate for administrator Bill Keck #7001996740 expires 8/21/25. Per Administrator, required documentation to renew their certificate has been submitted to the department's certification unit. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: LIC500- Personnel Report LIC308- Designation of Responsibility LIC610E- Disaster Plan Evidence of Liability Insurance No deficiencies cited during today's visit. Exit interview conducted with RHS Sharon Shnell-Hobbs and copy of this report was given.the state’s words, verbatim · CDSS document, Jul 29, 2025

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Staff did not ensure facility was kept free of mold

Licensing Program Analyst Leibert arrived unannounced for the purpose of investigating this complaint. LPA met with the Administrator and privately with the residents of the apartment which is the subject of this complaint. The following determinations are made: An anonymous Complainant has alleged that staff have not ensured that facility is free from mold; Resident (R1) first noticed possible mold in apartment, located in the independent section of the facility, and notified management on 1/26/2025; Management responded on 1/27 with a maintenance team and remediation group assessed the situation and determined there was mold in the bathroom and laundry room of the apartment; repairs were began immediately; R1 states that the facility management responded to R1's report quickly and that there has been ongoing repairs made to the areas where mold was found; R1 has stated satisfaction with the facility's response and indicates the response was timely. Based upon observations and statements, this complaint is UNFOUNDED, meaning that it is false or without a reasonable basis. Complaint is DISMISSED. Report left. No citations issued today. Unfoundedthe state’s words, verbatim · CDSS document, Feb 7, 2025 · control 21-AS-20250130111931

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs), Alviso and Loera, arrived unannounced to conduct a Required-1 Year Inspection. Stationed at the front entrance of the facility there is a security guard who screens visitors upon entry; LPAs were provided a parking pass and allowed entry onto the grounds. LPAs met with Administrator Bill Keck, Skilled Nursing Administrator Dan Skillman (back-up RCFE Administrator), and Director of Resident Health Services (RHS), Sharon Shnell-Hobbs. Fire clearance is approved for six hundred and seventy-nine (679) may be non-ambulatory, of which two (2) may be bedridden. Hospice waiver approved for forty (40) residents. Approved delayed egress in memory care unit. Facility has a required emergency disaster plan. Facility has a required infection control plan. Last evacuation drill was held on 6/7/24, and last fire drill was 6/7/24, per review of records. LPA discussed the emergency plan regarding emergency drills, these are to be conducted quarterly per H&S Code. LPAs reviewed five (5) resident files. All were complete. LPAs reviewed five (5) staff files. Staff had criminal record clearance as required. Staff had first aid and CPR certification as required. Staff had required training. LPAs toured the facility grounds with RHS Sharon, memory care unit, and assisted living units.pendent units. Hot water was checked at 119.1 degrees Fahrenheit. All exits were observed to be clear of obstruction. Fire extinguishers were tagged and serviced- dated 1/9/2024. LPAs observed a sufficient supply of food. Medications were centrally stored as required, including refrigerated medications. Medications are kept in medication carts, including double locked narcotic medications. All exits doors, walkways, and breezeways had sufficient room for residents to ambulate and were found to be clear. LPA is requesting the following documents be updated and submitted by 9/16/24. LIC308 - Designation of Administrator Responsibility LIC500 - Personnel Report -ensure all staff are listed/titles/days & hours working LIC610E-Emergency Disaster Plan (ensure to review and update as needed/required) Continued on LIC809C.. Infection Control Plan (ensure to review and update as needed/required) Copy of LIC400 Handling of Client Cash Resources (include copy of surety bond if handling cash) Form must be completed by all licensees. Copy of current Administrator Certificate Deficiencies observed during the inspection. LPAs observed that two (2) stairwells out of four (4) lacked the required evacuation chair; This was the building that consists of assisted living units, and a memory care unit. LPAs observed in the additional 14 buildings, having a total of 28 stairwells; 12 of these stairwells lacked the required evacuation chair, per H&S Code. This deficiency will b cited, HSC 1569.695(f)(1) Emergency Plans - An evacuation chair at each stairwell, on or before July 1, 2019, see LIC809D. LPAs obtained photos. LPAs observed two (2) housekeeping/cleaning carts that had numerous cleaners/disinfectants stored in them and unlocked, making them accessible to residents in care, one unsupervised cart was outside in the walkway of assisted living units, the other unsupervised cart was in an assisted living building, turned around and facing a wall. This deficiency will be cited, 87309(a) Storage Space- Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients, see LIC809D. LPAs obtained photos. Deficiencies 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. Appeal rights provided to the Administrator. Exit interview conducted with Administrator Bill Keck.the state’s words, verbatim · CDSS document, Aug 16, 2024

Allegation investigated: Staff refused to administer medication to resident

At approximately 8:20AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a Complaint Investigation regarding the above allegation and met with Executive Director, Bill Keck and Health Care Administrator, Dan Skillman. During the course of the investigation, the Department requested and reviewed documents, and made observations. There is an allegation that “Staff refused to administer medication to resident.” Complainant alleges that facility did not provide medication to Resident 1 (R1) on 12/17/2023, 12/18/2023, 12/19/2023, 12/20/2023, 12/21/2023, and 12/22/2023. Complainant alleged that Morphine was not provided to R1 on the following dates, 12/20/2023, 12/21/2023, and 12/22/2023 when R1’s private caregivers requested it, and that facility did not provide Lorazepam (Ativan) to R1. Complainant stated that R1’s private caregivers had documentation on when medication was requested and when medication was refused to be given. Attempts to obtain private caregiver contact information and the documentation were unsuccessful. Continued on LIC9099C Unsubstantiated Continued from LIC9099 Review of R1’s Electronic Medication Administration Record (EMAR) for December 2023, showed that R1 had two routine morphine orders to be given twice a day. Review of R1’s EMAR indicated that the facility administered the routine morphine orders on 12/15/223, 12/16/23, 12/17/23, and 12/18/23. These two orders were discontinued on 12/15/2023 and 12/18/2023. R1 also had a PRN morphine order to be administered as needed for pain or trouble breathing and a PRN Lorazepam order to be administered as needed for anxiety. Review of R1’s EMAR showed that facility staff administered PRN Morphine and PRN Lorazepam two times to R1 on 12/22/2023. Facility Progress Notes stated that on 12/19/2023, R1’s private caregiver said R1 needed Ativan. Per notes, the facility nurse observed R1 to be calm and peaceful. When the facility nurse asked R1 if they wanted Ativan, R1 stated no. Facility Progress Notes also stated that on 12/21/2023, the facility nurse received a call from R1’s private caregiver asking for Ativan. Facility Nurse and Certified Nursing Assistant (CNA) went to R1 to assess. Facility nurse and CNA observed R1 to be in a calm and pleasant mood. When R1 was asked how they were feeling, they stated they were fine. When R1 was asked if they felt anxious or if they wanted Ativan, R1 stated no. Review of R1’s Physician’s Report, dated 12/25/2022, stated that R1 can communicate their needs. Based on document review and observations made, this allegation is Unsubstantiated. A finding that the complaint allegation is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. No Deficiencies Cited during visit. Exit interview conducted. Copy of report discussed and provided to Executive Director. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, May 10, 2024 · control 21-AS-20231222163620

Allegation investigated: Fraudulent Billing

Christina Hadley investigated the allegations into possible violations of contuning care statutes. During the course of the investiation it was determined that the facility experienced a glitch in their electronic billing system. This matter has since been addressed and affected residents have either been credited for overcharges, or billed additionally for charges that should have been billed but had not. Although this glitch caused an inconvenience to some residents, there is no proof that this incident was done with ill intent or malice. As of this date, the Executive Director attests to the fact that the system is working properly and that the community has had no new complaints/concerns from residents about being billed multiple times for services. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that alleged abuse occurred. Unsubstantiatedthe state’s words, verbatim · CDSS document, May 10, 2024 · control 21-AS-20240202174028

Allegation investigated: Personal Rights (Fraudulent Billing)

Christina Hadley investigated the allegations into possible violations of contuning care statutes. During the course of the investiation it was determined that the facility experienced a glitch in their electronic billing system. This matter has since been addressed and affected residents have either been credited for overcharges, or billed additionally for charges that should have been billed but had not. Although this glitch caused an inconvenience to some residents, there is no proof that this incident was done with ill intent or malice. As of this date, the Executive Director attests to the fact that the system is working properly and that the community has had no new complaints/concerns from residents about being billed multiple times for services. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that alleged abuse occurred. Unsubstantiatedthe state’s words, verbatim · CDSS document, Apr 26, 2024 · control 21-AS-20240202174028