Spring Lake Village

Name: Spring Lake Village
Address: 5555 MONTGOMERY DRIVE, Santa Rosa, CA, 95409, US
Telephone: 7075388400

5555 Montgomery Drive, Santa Rosa, CA 95409 · Sonoma County · 70 certified beds · avg 42 residents/day · certified since Dec 4, 1986

Part of chain: FRONT PORCH (9 facilities, chain avg rating 4.8★)

4/5

Health inspection rating (on-site)

Serious findings on record

Fines, last 3 years

6.36

Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★★★☆4/5 · CMS overall rating: 5/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

All citations in the current public record (26)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

Date	Severity	What the facility was cited for
Jan 22, 2026	E · Potential for harm, repeated	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Jan 22, 2026	D · Potential for harm, one-off	The facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment.
Jan 22, 2026	D · Potential for harm, one-off	The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own.
Jan 22, 2026	D · Potential for harm, one-off	The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Apr 15, 2025	D · Potential for harm, one-off	The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint
Feb 13, 2025	F · Potential for harm, facility-wide	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Feb 13, 2025	F · Potential for harm, facility-wide	The facility did not include required infection control training — with written standards, policies, and procedures — as part of its infection prevention program.
Feb 13, 2025	E · Potential for harm, repeated	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Feb 13, 2025	D · Potential for harm, one-off	The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups.
Feb 13, 2025	D · Potential for harm, one-off	The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs.
Feb 13, 2025	D · Potential for harm, one-off	The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Feb 13, 2025	D · Potential for harm, one-off	The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Feb 13, 2025	D · Potential for harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Feb 13, 2025	D · Potential for harm, one-off	The facility did not provide safe and appropriate pain management for a resident who needed it.
Feb 13, 2025	D · Potential for harm, one-off	The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time.
Feb 13, 2025	D · Potential for harm, one-off	The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.
Feb 13, 2025	D · Potential for harm, one-off	The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Feb 13, 2025	D · Potential for harm, one-off	The facility did not have enough support staff to safely and effectively run its food and nutrition service.
Feb 13, 2025	D · Potential for harm, one-off	The facility did not have a policy covering how food brought in by family and visitors is used and stored safely.
Feb 13, 2025	D · Potential for harm, one-off	The facility did not dispose of garbage and refuse properly.
Apr 7, 2023	F · Potential for harm, facility-wide	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Apr 7, 2023	F · Potential for harm, facility-wide	The facility did not dispose of garbage and refuse properly.
Apr 7, 2023	E · Potential for harm, repeated	The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required.
Apr 7, 2023	E · Potential for harm, repeated	The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle.
Apr 7, 2023	D · Potential for harm, one-off	The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow.
Apr 7, 2023	D · Potential for harm, one-off	The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.

Inspection trend by year

Citations from standard inspections decreased between the last two inspection cycles (15 → 4).

Year	Citations	Worst severity that year
2023	6	F
2025	16	F
2026	4	E

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

No fines or payment denials in the published 3-year window.

Nurse staffing (from payroll records, adjusted for how much care residents need)

Measure	This facility	California avg	U.S. avg	Where it stands
Total nurse staffing (hours per resident per day)	6.36	4.31	3.95	top 4% in California; top 3% in the U.S.
Registered Nurse hours	1.27	0.61	0.69	top 6% in California; top 8% in the U.S.
Weekend total nurse staffing	5.57	3.90	3.50	top 4% in California; top 3% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.81	0.51	0.48	top 11% in California; top 11% in the U.S.
Total nursing staff turnover (%)	22.1	36.7	45.8	top 11% in California; top 4% in the U.S.
RN turnover (%)	20.0	38.1	42.9	top 19% in California; top 13% in the U.S.

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 5.54, RN 1.10, weekend 4.85. Staffing rating: 5/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: 5/5

Who owns this facility

Non profit - Corporation

Owner / manager	Type	Role	Stake	Since
Front Porch Communities and Services	Organization	5% or Greater Direct Ownership Interest	100%	04/01/2022
Akopyan, Gevork	Individual	Operational/Managerial Control	NOT APPLICABLE	10/12/2022
Bout, Ferdinand	Individual	Operational/Managerial Control	NOT APPLICABLE	12/29/2025
Duranteau, Nancy	Individual	Corporate Director	NOT APPLICABLE	04/01/2021
Forte, Vincent	Individual	Corporate Director	NOT APPLICABLE	04/01/2021
Front Porch Communities and Services	Organization	ADP of the SNF	NOT APPLICABLE	04/01/2022
Handy, Joanne	Individual	Corporate Director	NOT APPLICABLE	04/01/2021
Ichien, Christopher	Individual	Operational/Managerial Control	NOT APPLICABLE	06/04/2018
Jacobs, Laura	Individual	Corporate Director	NOT APPLICABLE	01/01/2019
Jumawan, Kristyl	Individual	Operational/Managerial Control	NOT APPLICABLE	01/20/2026
Kelly, Sean	Individual	Corporate Officer	NOT APPLICABLE	03/06/2023
Kelly, Sean	Individual	Operational/Managerial Control	NOT APPLICABLE	03/06/2023
Kroeker, Kevin	Individual	Corporate Director	NOT APPLICABLE	01/01/2018
Macango, Susan	Individual	Operational/Managerial Control	NOT APPLICABLE	05/04/2026
McGovern, Marion	Individual	Corporate Director	NOT APPLICABLE	01/01/2017
McMullin, Mary	Individual	Operational/Managerial Control	NOT APPLICABLE	04/01/2025
Olson, Kari	Individual	Operational/Managerial Control	NOT APPLICABLE	04/01/2021
Salvador, Eduardo	Individual	Corporate Director	NOT APPLICABLE	10/03/2017
Salvador, Eduardo	Individual	Operational/Managerial Control	NOT APPLICABLE	04/01/2021
Skillman, Daniel	Individual	Operational/Managerial Control	NOT APPLICABLE	04/05/2021

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

"Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
"What is your policy on physical restraints, and what alternatives do you try first?"
"How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
"How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
"When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
"How are staff trained on infection control, and how often is that training refreshed?"
"What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
"Can you give me examples of how you adjust daily routines and room setups to fit each resident's preferences?"
"What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
"Can I see the results and plan of correction from your most recent state inspection?"

Nearby facilities (within 20 miles)

Facility	Distance	City	Overall	Inspection	Flags
Summerfield Health Care Center	1.4 mi	Santa Rosa, CA	★★★★★	5/5
Park View Post Acute	1.6 mi	Santa Rosa, CA	★★☆☆☆	2/5	abuse
Santa Rosa Post Acute	2.0 mi	Santa Rosa, CA	★★★☆☆	2/5
Blue Oak Post-Acute	4.0 mi	Santa Rosa, CA	★★☆☆☆	1/5	abuse
Northvine Postacute Care	5.0 mi	Santa Rosa, CA	★☆☆☆☆	1/5
Arbol Healthcare Center of Santa Rosa	5.0 mi	Santa Rosa, CA	★★★★★	4/5
Apple Valley Post-Acute Rehab	10.8 mi	Sebastopol, CA	★★★★★	4/5
Vineyard Post Acute	13.9 mi	Petaluma, CA	★★★☆☆	2/5
Valley of the Moon Post Acute	14.9 mi	Sonoma, CA	★★★☆☆	2/5	abuse
Sonoma Post Acute	15.2 mi	Sonoma, CA	★★★★☆	3/5
Broadway Villa Post Acute	15.7 mi	Sonoma, CA	★★★★★	3/5
Veterans Home of California - Yountville - SNF	15.8 mi	Yountville, CA	★★★★★	4/5

Compare this facility with the 3 closest →

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Facility data as of CMS processing date 2026-08-01. CCN 555268.

The Care File

Visit checklist — Spring Lake Village

5555 Montgomery Drive, Santa Rosa, CA 95409 · 7075388400

Health inspection rating 4/5 · CMS overall 5/5· Fines (3y): $0

Questions for the administrator:

☐ "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
☐ "What is your policy on physical restraints, and what alternatives do you try first?"
☐ "How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
☐ "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
☐ "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
☐ "How are staff trained on infection control, and how often is that training refreshed?"
☐ "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
☐ "Can you give me examples of how you adjust daily routines and room setups to fit each resident's preferences?"
☐ "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
☐ "Can I see the results and plan of correction from your most recent state inspection?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 555268 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)