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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216801691
Report Date: 08/04/2022
Date Signed: 08/04/2022 12:21:29 PM


Document Has Been Signed on 08/04/2022 12:21 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



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:
08/04/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Cynthia Viarata - AdministratorTIME COMPLETED:
12:21 PM
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Licensing Program Analyst (LPA) Fernandes-Goes arrived to conduct a case management visit regarding two incident reports submitted to Community Care Licensing (CCL) for R1 & R2 which occurred on 6/16/2022. LPA met with Cynthia Virata - Administrator.

On both occasions resident R1 & R2 AWOL/eloped while under facility responsibility. Resident R1 has a physician's report dated 2/3/2021 diagnostic of dementia and R2 dated 9/21/2020 diagnostic of MCI which states that residents are NOT able to leave facility unassisted at any time. Per facility staff resident R1 walked out of the facility and was found by staff on sidewalk on Tamalpais Ave while resident R2 was found by staff at wine festival. It seems that both residents left facility together. (see confidential name list, copies, LIC 809-D)

Since this incident, facility has conducted staff training for elopement and facility elopement plan in which both have been submitted to the Department as prove of correction. (copy on file) Precautions have been taken by facility to avoid any other incident of elopement.


The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided. Appeal of Rights Given.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2022
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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Document Has Been Signed on 08/04/2022 12:21 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: CREEKWOOD
FACILITY NUMBER: 216801691

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/05/2022
Section Cited

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8746(f)(c) Basic Services. This requirement isn't meet as evidenced by: Based on incident reports Resident R1 & R2 eleoped from facility without staff knowledge on 6/18/22 the facility didn't comply on safetymeasures
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to address behaviors such as wandering for residents R1 & R2 which poses an immediate Health,Safety risk to residents in care.Per staff interviews,SIRs, & physician's reports, R1&2 left the facility w/out staff knowledge. (see copies)
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 08/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2022
LIC809 (FAS) - (06/04)
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