Springfield Place

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Hansen arrived unannounced to conduct a Required - 1 Year visit, on 10/21/25 at approximately 8:15am, and was greeted by staff, Tracy Nava, Health & Wellness Director (HWD) who contacted Administrator Stacy Ford that arrived during inspection. Facility has a hospice care waiver approved for six (6) residents. Fire clearance approval is for one hundred and twelve (112) non-ambulatory residents. The facility consists of two floors and provides assisted living services to residents as needed. During today’s visit there were 95 residents with one (1) under hospice care. LPA and HWD toured the facility finding; all exits were free and clear of any obstructions. All five (5) stairwells had the required evacuation chairs. Fire Extinguishers were found to be last charged on 6/19/2025 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. Every resident apartment has an individual smoke detector in addition to hard wired, which smoke and carbon monoxide detectors were found to be operational on today’s visit. Hot water temperature measured between 114 degrees F and 120 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 6 resident’s bathroom faucets while touring facility on 10/21/2025 at 9:00 AM. Bathrooms were equipped with necessary grab bars, and slip-resistant mats, strips, or flooring in all bathtub and shower floors as required by Title 22 regulations. All bedrooms have lighting & appropriate furnishings per Title 22 regulations. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerators/freezers/storage rooms, was properly stored as per regulations on this day at the time of the visit. The facility had sufficient supplies of cleaners/disinfectants, paper products, emergency 72-hour shelter in place supplies, emergency water supplies, and sufficient supply of personal protective equipment (PPE). Continue on LIC809C Continued from LIC809 Facility had sufficient lighting in all inspected hallways, bathrooms, and common areas. Facility was at a comfortable temperature during the inspection. All medications were locked /centrally stored and inaccessible to residents in care. Audit of medications showed all in compliance during today’s visit. All cleaners/disinfectants/toxins were locked and inaccessible to residents in care. At approximately 10:30am LPA reviewed six (6) resident records. All records were complete including Care Plans/Assessments/Re-assessments. Based on file review there are residents with dementia diagnosis. LPA will follow up regarding the plan of operations (POO) with Administrator. At approximately 11:45 LPA reviewed six (6) staff records. All staff records reviewed along with additional staff have criminal record clearance as required by regulation. LPA reviewed staff training records. All staff had required training. Staff have First Aid and CPR certification as required. Facility holds required emergency disaster drills on a bi- monthly basis, with all shifts ensuring all staff participate in the evacuation drills. Last drills were held 9/24/2025. Administrator Certificate for Stacy Ford 7024907740 expires 4/4/2027. No deficiencies cited during today's inspection. Exit interview conducted with Administrator Stacy Ford Documents required from annual inspection provided by Administrator at visit.the state’s words, verbatim · CDSS document, Oct 21, 2025

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced at facility to conduct a Health & Safety check and met with Administrator, Stacy Ford. Community Care Licensing (CCL) received an email on 6/16/2025 regarding damaged sprinkler head malfunction in back of the facility kitchen. There were no immediate health hazards of concern. At approximately 11:30am on 6/17/2025 LPA and Administrator toured the kitchen observing replacement walk in refrigerator/freezer that had been under construction when incident occurred, was continuing with replacement in place. Also observed in parking lot, a refrigeration truck and a truck containing freezer products facility had in use for change out prior to sprinkler pipe "riser" being broken. Kitchen and dining staff were serving lunch prepared in kitchen. Administrator informed LPA, incident occurred at approximately 11am 6/16/25 and residents were brought in dinner from outside vendor last night although food storage and kitchen was back to status quo as of late last night. LPA requested incident report and updates on repairs. No citations given at today's visit.the state’s words, verbatim · CDSS document, Jun 17, 2025

Allegation investigated: Staff did not make resident records available to resident's authorized representative

Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced to initiate a complaint investigation and subsequently was able to deliver findings regarding the allegation listed above. LPA met with Administrator, Stacy Ford. During investigation LPA made observations, reviewed documents and conducted interviews. Staff did not make resident records available to resident's authorized representative- Reporting party alleges, authorized representative requested resident records on 03/20/2025 and as of 04/2/2025, no records had been produced. LPA obtained documentation on 4/4/2025 of resident records being requested on 3/20/2025 from facility by resident authorized representative and email response from facility Administrator on 3/27/2025 record request is being worked on and an update on the request will be provided by end of next week (4/4/25). Continue on LI9099-C Substantiated Continued from LIC9099 During today’s visit, documents obtained and interview with Administrator corroborate with reporting party that on 3/20/2025 resident’s representative, requested resident records with appropriate legal confirmation indicating proof of legal representation and did not provide resident records within Title 22 Regulation 87468.2(a)(19) time frame of two (2) business days. There was sufficient information obtained to support a violation occurred. Therefore, allegation “staff did not make resident records available to resident’s authorized representative” is SUBSTANTIATED. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were observed (see LIC 9099D) 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.the state’s words, verbatim · CDSS document, Apr 8, 2025 · control 21-AS-20250402101124

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(19) · Plan of correction due date: Apr 11, 2025

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (19) To have prompt access to review all of their records and to purchase photocopies of their records. Photocopied records shall be provided within two (2) business days and at a cost that does not exceed the community standard for photocopies. This requirement is not met as evidenced by: Based on record review & interviews the licensee did not comply with the above regulation by not providing the requested documents to authorized representative within two (2) business days, which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 8, 2025

Plan of correction: Licensee agrees to review regulation 87468.2 (a)(19) and submit self certification acknowledging the understanding of the regulation.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Alviso conducted a Required - 1 Year visit, on 12/30/24 at approximately 2:25pm, and met with Administrator Stacy Vermeulen. Hospice care waiver approved for six (6) residents. Facility has a required infection control plan, and a required emergency disaster plan. Fire clearance approval is for one hundred and twelve (112) non-ambulatory residents. The facility consists of two floors, and provides assisted living services to residents as needed. LPA reviewed six (6) resident records. All records were complete. The LPA reviewed six (6) staff records. All staff have criminal record clearance as required by regulation. LPA reviewed staff training records. All staff had required training. Staff have First Aid and CPR certification as required. Facility holds required emergency disaster drills on a monthly basis, ensuring all staff participate in the evacuation drill; Requirement is that emergency drills are held quarterly, an evacuation drill, and three other drills. Drills must be held for every shift. Administrator stated their understanding of meeting the requirement. LPA toured the facility with the Administrator All exits were free and clear of any obstructions. Fire extinguishers were serviced and tagged as required. All five (5) stairwells had the required evacuation chairs. There is also an evacuation chair stored that can be used for the main staircase that leads downstairs to the first floor. The hot water was checked at 110.0 degrees Fahrenheit and 116.2 degrees Fahrenheit which is within regulation. The facility had a sufficient supply of food, perishable and non-perishable. LPA discussed food regulation requirements, with lead kitchen staff and the Administrator, regarding food storage, to ensure no contamination of food supplies. The facility had sufficient supplies of cleaners/disinfectants, paper products, emergency 72-hour shelter in place supplies, emergency water supplies, and sufficient supply of personal protective equipment (PPE). Facility had sufficient lighting in all inspected hallways, bathrooms, and common areas. Facility was at a comfortable temperature during the inspection. All medications were locked up/centrally stored and inaccessible to residents in care. All cleaners/disinfectants/toxins were locked up and inaccessible to residents in care. Administrator has completed the annual updated forms, and will scan them to the licensing office email address. No deficiencies cited during today's inspection. Exit interview conducted with Administrator Stacy Vermeulen.the state’s words, verbatim · CDSS document, Dec 30, 2024

Type of visit: Case Management - Annual Continuation

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 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..the state’s words, verbatim · CDSS document, Oct 5, 2023

Type of visit: Required - 1 Year

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 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.the state’s words, verbatim · CDSS document, Oct 3, 2023