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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216801691
Report Date: 12/22/2021
Date Signed: 12/23/2021 08:51:16 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: 38DATE:
12/22/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Cynthia Virate - AdministratorTIME COMPLETED:
10:55 AM
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Licensing Program Analyst (LPA) Fernandes-Goes arrived unannounced with the purpose of closing a complaint investigation. During subsequent complaint investigation LPA learned there are related deficiencies observed during the visit. LPA met with Cynthia Virata - Administrator. Following item were observed during investigation visits:

LPA observed during interviews and resident's files review on 9/29/2021 & 11/22/2021 that facility has had a medication error on 9/27/2021. Resident R1 had a medication order discontinued by doctor on 9/20/2021 & 9/24/2021. Medication technician staff S1 dispensed discontinued order of 3 x 75 mg Clozapine and new order of 3 x 100 mg Clozapine dated 9/20/2021 instead only 3 x 100 mg of Clozapine until 9/26/2021. As per administrator, doctor and family member were contacted. Staff S1 received retraining on Relias on 10/6/2021. Per staff S1 interview, discontinued doctor's orders for 3 x 75 mg Clozpine wasn't submitted to the facility until 2 days later of new order.




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: 12/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021
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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