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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216801691
Report Date: 08/25/2020
Date Signed: 08/25/2020 09:43:44 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/08/2020 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20200608082051
FACILITY NAME:CREEKWOODFACILITY NUMBER:
216801691
ADMINISTRATOR:PAULA SAUVEFACILITY TYPE:
740
ADDRESS:830 TAMALPAIS AVETELEPHONE:
(415) 897-2661
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY:62CENSUS: DATE:
08/25/2020
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Paula Sauve - AdministratorTIME COMPLETED:
09:30 AM
ALLEGATION(S):
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Facility failed to ensure that resident was adequately hydrated
Facility staff handled resident in a rough manner
INVESTIGATION FINDINGS:
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Licensing Program Analyst Leibert contacted Administrator Paula Sauve, this date, for the purpose of delivering findings on the above captioned complaint allegations. The visit was conducted via tele - visit due to the COVID - 19 precautions. It is alleged that staff have handled R1 in a rough manner and have not ensured R1 is adequately hydrated. The allegations are denied. This Department has obtained records and interviewed staff and witnesses. The following determinations have been made: R1 has a medical condition that often results in dehydration; R1 requires thickened liquids and is often reluctant to drink sufficient amounts; Staff have called 911 in May and in June due to R1's apparent dehydration; Care notes indicate R1 was checked frequently by staff and was encouraged to drink fluids; Responsible person for R1 sates that R1 has no complaints regarding R1's care at the facility; R1 has physical limitations that make transfer and changing of R1 difficult and uncomfortable. Continued on second page......
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 21-AS-20200608082051
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: CREEKWOOD
FACILITY NUMBER: 216801691
VISIT DATE: 08/25/2020
NARRATIVE
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Although the allegations may be true, or are valid, based upon the records reviewed and the statements taken, there is not a preponderance of evidence to prove the allegations did, or did not, occur. Therefore, the allegations are UNSUBSTANTIATED.
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 2