216801691-1-26-2024-21-AS-HRUS-CZUVBK-20240126151741

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216801691
Report Date: 01/26/2024
Date Signed: 01/26/2024 03:17:58 PM

Document Has Been Signed on 01/26/2024 03:17 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	CREEKWOOD		FACILITY NUMBER:	216801691
ADMINISTRATOR:	HYLTON, RACHEL		FACILITY TYPE:	740
ADDRESS:	830 TAMALPAIS AVE		TELEPHONE:	(415) 897-2661
CITY:	NOVATO	STATE: CA	ZIP CODE:	94947
CAPACITY:	62	CENSUS: 33	DATE:	01/26/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Co-Administrator, Nancy Morquecho		TIME COMPLETED:	03:30 PM

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	At approximately 9:00 AM Licensing Program Analyst (LPA) Helena Rummonds arrived unannounced to conduct an annual required inspection and met with Administrator, Nancy Morquecho. LPA and Administrator discussed the purpose of the visit. LPA and Administrator initiated a tour of the facility around 9:15 AM and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Water temperature in sinks accessible to residents measured at 112, 107, 113, 112, and 118 degrees F which are within the range of 105 to 120 degrees F allowed per regulation. Extra hygiene products and linens were available. Cleaning supplies were stored in closet in kitchen, separate from food storage. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation. Medications were centrally stored. LPA observed the medication room door to be open leaving medications accessible to residents in care. Administrator immediately closed and locked the medication room door. Emergency food and water supplies are rotated to keep them from expiring, and are stored in the facility kitchen. Personal Protective Equipment is stored in an outdoor storage shed. Fire extinguishers were last serviced November 2023. Facility has combination Smoke/ Carbon Monoxide detectors and a sprinkler system which was last inspected by the fire department on 12/13/2023. Most recent fire/disaster drill was conducted on 11/10/2021. LPA confirmed with Administrator that drills are to be conducted on a quarterly basis, as per Title 22 regulations. Continued on LIC809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Helena Rummonds	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024

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 01/26/2024 03:17 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: CREEKWOOD	FACILITY NUMBER: 216801691
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(h)(2)

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by 1 of 1 medication storage rooms with the door open without staff present which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/27/2024
	Plan of Correction
1 2 3 4	Licensee agrees to submit self certification stating that the medication room will remain locked with the door closed when staff are not actively utilizing the medication room.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Helena Rummonds	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: CREEKWOOD	FACILITY NUMBER: 216801691
	VISIT DATE: 01/26/2024

NARRATIVE

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Continued from LIC809

5 staff files and 5 resident files were reviewed. Staff have required First Aid and CPR certificates. Training records were reviewed. Administrator Certificate for Co-Administrator, Rachel Hylton (6038480740), is up to date and expires 03/03/2024. Medications and medication records were reviewed. LPA observed medications to be pre-poured up to one day ahead. LPA had a conversation with Administrator and Med Tech on duty reminding them that medications are to remain in the original container in which the medication was received in until administration.

Per conversation with Administrator, there are currently 8 residents in the facility who are bedridden. Facility currently has a fire clearance for 0 bedridden residents. LPA is requesting the following to update the facility fire clearance:
-Updated facility sketch indicating which bedrooms are for bedridden residents
-Updated LIC200 requesting bedridden fire clearance in section 1b

LPA is requesting the following documents to be submitted to CCL by 02/26/2024:
LIC 500 Personnel Report
Liability Insurance
LIC 9020 Resident Roster
LIC308 Designation of Facility Responsibility

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted. Copy of report, LIC 809D, Appeal Rights, discussed and provided to Administrator. Signature on form confirms receipt of documents.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Helena Rummonds	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/26/2024 03:17 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: CREEKWOOD	FACILITY NUMBER: 216801691
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above by which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/14/2024
	Plan of Correction
1 2 3 4	Administrator agrees to submit proof of disaster drills being conducted on each shift with a log of employee attendance. Administrator agrees to submit a plan for how often these drills will be conducted.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Helena Rummonds	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024

LIC809 (FAS) - (06/04)

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