<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216801691
Report Date: 12/14/2021
Date Signed: 12/14/2021 03:33:51 PM



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
09/27/2021 and conducted by Evaluator Carla Fernandes-Goes
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20210927164908
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:
12/14/2021
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Paula Sauve - LicenseeTIME COMPLETED:
02:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident sustained injuries while in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
The Department conducted a complaint investigation regarding the allegation listed above. Licensing Program Analyst Fernandes-Goes arrived unannounced for the purpose of closing the investigation and met with Paula Sauve - Licensee.

On 9/29/2021, LPA Fernandes-Goes toured the facility; conducted interviews; acquired documentation; and made observations of the facility. During documentation review on file and observations with Cynthia Virata Administrator, and interviews of staff and resident R1, LPA learned that facility resident R1 was found with an injury; 911 was contacted; and resident was sent out to the ER. Per staff interview, “Resident R1 on 9/26/21 at 10:35 AM was observed by caregiver and called Med tech who enter the room to assist resident. Resident R1 had leg caught between rail and bed; staff noticed deep cut; 911 was contacted came back from hospital at 2:55 PM.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2021
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-20210927164908
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: 12/14/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
It looked like she tried to move away and her leg got cut. Based on observation, interviews, and documentation review LPA wasn’t able to prove or disprove that facility staff neglected resident R1 while in care. R1 sustained injury although LPA obtained no evidence to support facility negligence and when injury was observed timely medical was provided.

A finding that the complaint allegation of “Resident sustained injuries while in care.” is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.


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

DATE: 12/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2