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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216801691
Report Date: 01/14/2025
Date Signed: 01/14/2025 04:29:04 PM

Document Has Been Signed on 01/14/2025 04:29 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:CREEKWOODFACILITY NUMBER:
216801691
ADMINISTRATOR/
DIRECTOR:		HYLTON, RACHELFACILITY TYPE:
740
ADDRESS:830 TAMALPAIS AVETELEPHONE:
(415) 897-2661
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY: 62TOTAL ENROLLED CHILDREN: 0CENSUS: 32DATE:
01/14/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:25 PM
MET WITH:Rachel Hylton, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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01/14/2025, Licensing Program Analyst (LPA) Loera conducted an unannounced Annual Required – 1 yr. inspection visit for this facility. Facility has an emergency disaster plan as required. Facility has an infection control plan as required. There are currently 32 residents in care. Facility approved/cleared for 62 non-ambulatory and hospice waiver for 16.

At approximately 1:00pm, LPA and Administrator toured the building and grounds. The facility was found to be at a comfortable temperature. LPA observed a 2 day supply of perishable and 7 day supply of non-perishable food. Refrigerated food was found to be stored in a safe manner being labeled and dated.

Medications were found to be centrally stored. All rooms were equipped with lighting, night stand, and chest of drawers. All rooms were in good repair. Extra hygiene products and linens were available for residents in care. Water temperature in sinks accessible to residents in care were measured at 114.0 and 116.4 degrees F which is within the range of 105 to 120 degrees F. During the walk through LPA observed residents to be participating in activities. Facility has a calendar for daily activities. Fire extinguishers were last inspected 10/2024. Facility has a generator surrounded by a fence. LPA observed outdoor patio to have caution tape around as it is currently under construction due to a recent storm eroding the hillside. Facility has emergency supplies located in a hallway closet. LPA conducted spot medication count and found all prescription medication to be properly recorded on the Centrally Stored Medication Record. Facility conducts quarterly fire and disaster drills with the last one being conducted on 12/10/2024.

LPA conducted a review of 8 resident records. All records had the required documentation. LPA conducted review of 8 staff records/training. Upon a review of staff records, LPA found all staff to have required annual and initial training as well as current 1st Aid & CPR certification on file.

continued on LIC809-C

Kimberley MotaTELEPHONE: (707) 588-5071
Anthony LoeraTELEPHONE: (707) 588-5026
DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/14/2025
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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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: 01/14/2025
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No deficiencies cited during today's inspection. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 02/14/2025 days of this visit:

LIC500- Personnel Report
LIC308- Designation of Responsibility
Emergency Disaster Plan (review, update if needed)
Infection Control Plan (review, update if needed)

Exit interview conducted with Administrator and a copy of this report was provided.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5071
LICENSING EVALUATOR NAME: Anthony LoeraTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025
LIC809 (FAS) - (06/04)
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