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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216801691
Report Date: 06/28/2021
Date Signed: 06/29/2021 09:11:59 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
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:CREEKWOODFACILITY NUMBER:
216801691
ADMINISTRATOR:PAULA SAUVEFACILITY TYPE:
740
ADDRESS:830 TAMALPAIS AVETELEPHONE:
(415) 897-2661
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY:62CENSUS: 35DATE:
06/28/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Paula Sauve - Licensee/AdministratorTIME COMPLETED:
04:15 PM
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Licensing Program Analyst Fernandes-Goes conducted an unannounced case management and met with Paula Sauve – Licensee. The purpose of the case management visit was to obtain additional information regarding SOC 341 submitted to the Regional Office by the facility on 6/23/2021.

LPA acquired documentation for resident & staff, interviewed resident, met with licensee, and toured the facility. In addition, facility has contacted the police who has opened and closed the case. (see copies of documentation and interview on file)
Resident R1 is doing well and is content with facility staff.


No deficiencies cited during today’s visit.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2021
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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