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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490107656
Report Date: 08/20/2026
Date Signed: 08/20/2026 05:16:01 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 08/20/2026 05:16 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:SPRING LAKE VILLAGEFACILITY NUMBER:
490107656
ADMINISTRATOR/
DIRECTOR:		FERDINAND BUOTFACILITY TYPE:
741
ADDRESS:5555 MONTGOMERY DRIVETELEPHONE:
(707) 538-8400
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY: 679CENSUS: 30DATE:
08/20/2026
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:01 AM
MET WITH:Ferdinand Buot, AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
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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

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Victoria Bertozzi
Christi Coppo
DATE: 08/20/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: SPRING LAKE VILLAGE
FACILITY NUMBER: 490107656
VISIT DATE: 08/20/2026
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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


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NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/20/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2026
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: SPRING LAKE VILLAGE
FACILITY NUMBER: 490107656
VISIT DATE: 08/20/2026
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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.
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/20/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2026
LIC809 (FAS) - (06/04)
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