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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
216801691
Report Date:
12/22/2022
Date Signed:
12/22/2022 02:54:53 PM
Document Has Been Signed on
12/22/2022 02:54 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:
CREEKWOOD
FACILITY NUMBER:
216801691
ADMINISTRATOR:
PAULA SAUVE
FACILITY TYPE:
740
ADDRESS:
830 TAMALPAIS AVE
TELEPHONE:
(415) 897-2661
CITY:
NOVATO
STATE:
CA
ZIP CODE:
94947
CAPACITY:
62
CENSUS:
33
DATE:
12/22/2022
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
01:35 PM
MET WITH:
Cynthia Viarata - Administrator
TIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced on 12/22/2022 to conduct a Required 1 Year inspection. LPA met with administrator Cynthia Viarata. This inspection was focused on the infection control procedures and practices of this facility. LPA was screened upon entry. COVID postings were present at the front entrance.
LPA toured building and grounds with administrator which were clean and in good repair. Exits and walkways were free from obstructions. Facility had sufficient perishable and non-perishable food. Bathrooms are equipped with necessary grab bars and non-slip flooring. Medications were locked and secured in medication room. Toxins were secured and inaccessible. LPA observed carbon monoxide detectors throughout the facility. Fire extinguishers inspected were charged and current. Facility has sufficient personal protective equipment to support a resident in isolation. Staff have been given infection control training. Staff and residents have received COVID booster and flu shot. High touch surface areas are disinfected daily. LPA observed monthly activity schedule. Guitar and harp player were performing for residents during time of the inspection.
LPA is requesting the following documents be submitted to Community Care Licensing within 30 days of today's inspection:
LIC 308 Designation of Administrative Responsibility
Evidence of Liability Insurance
Exit interview conducted with Cynthia Viarata. Report was emailed to administrator. No deficiencies observed during today's inspection.
SUPERVISOR'S NAME:
Kimberley Mota
TELEPHONE:
(707) 588-5051
LICENSING EVALUATOR NAME:
Erik Gonzalez Campos
TELEPHONE:
(707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE:
12/22/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/22/2022
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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