496803282-9-28-2023-21-AS-MCUA-CW4S7U-20230928133806

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803282
Report Date: 09/28/2023
Date Signed: 09/28/2023 01:38:19 PM

Document Has Been Signed on 09/28/2023 01:38 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:	SPRING CREEK LODGE		FACILITY NUMBER:	496803282
ADMINISTRATOR:	ALCONES, LILY		FACILITY TYPE:	740
ADDRESS:	3650 SPRING CREEK DRIVE		TELEPHONE:	(707) 523-3255
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95405
CAPACITY:	6	CENSUS: 6	DATE:	09/28/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:49 AM
MET WITH:	Arthur Alcones (Administrator)		TIME COMPLETED:	01:52 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	Licensing Program Analysts (LPA) Cuarda and Coppo conducted an unannounced Annual Required – 1 yr. and was welcomed by Aaron Salvador Caregiver. Administrator Arthur Alcones arrived shortly after. There were 6 residents present at the facility with 1 resident on hospice. Required postings observed. LPA toured the facility around 9:15 am with Administrator Arthur Alcones. During tour on 9/28/2023 facility was found to be clean and at a comfortable temperature with all exits free from obstruction. At around 9:30 am LPAs/Administrator observed that back deck has wood scrap piles with nails protruding. Administrator explained that they are remodeling and the pile of wood waste is temporary. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers were found to be last charged on 9/15/23 at the time of the visit. Smoke Detectors & Carbon monoxide detectors were found to be operational during the visit. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Last disaster drill was conducted on 09/06/2023. Medications and medication records were reviewed. Hot water temperature; it measured 118.7 degrees F which is within acceptable regulations of 105 to 120 degrees F in 1 out of 2 resident’s bathroom faucets. There was a supply of cleaners, hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings. Toxins are secured and inaccessible in locked garage cabinets. Based on interviews with residents and LPAs/Administrator observation there are some discrepancies with statements obtained from residents about the facility providing limited activities for them. LPAs/Administrator had a conversation about the importance to provide a variety of activities for residents in care. Administrator agreed to review and develop a current activity calendar. LPAs will be issuing a technical advisory. At approximate 10:00 am LPAs initiated file review. One out of six residents physician's report (R2) was not updated and five out of six residents' (R1, R2, R3, R4 & R5) care plans were not updated within the last 12 months as stated per regulations. Continues on LIC809C...

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: SPRING CREEK LODGE	FACILITY NUMBER: 496803282
	VISIT DATE: 09/28/2023

NARRATIVE

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Continued from LIC809...

During file review, LPAs/Administrator observed that two out of six residents (R3 & R5) physician's report stated that residents have a non-amb/bedridden status. Based upon interviews with residents, it was revealed that both are able to reposition on their sides without assistance. However, LPAs are instructing Administrator to obtain an updated physician's report clarifying status. LPAs discussed with Administrator process of fire clearance notifications including Fire Department and CCL regarding any bedridden status.

Administrator agreed to submit the following current documents by 10/12/2023: LIC500 Personnel Report, LIC308 Designation of facility responsibility, control of property, liability insurance and Infection Control Plan.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview was conducted with Licensee and a copy of this report was provided.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/28/2023 01:38 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: SPRING CREEK LODGE	FACILITY NUMBER: 496803282
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA and administrator observation and interviews with administrator back deck has wood scrap piles with nails protruding due to remodeling, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/29/2023
	Plan of Correction
1 2 3 4	Administrator agrees to remove piles of wood scraps today 9/28/2023. Administrator will submit a picture of cleared piles to notify CCL, by POC due date.

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: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

LIC809 (FAS) - (06/04)

Page: 3 of 6

Document Has Been Signed on 09/28/2023 01:38 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: SPRING CREEK LODGE	FACILITY NUMBER: 496803282
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87458(a)

Medical Assessment

(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA record review and interview with administrator, the licensee did not comply with the section cited above in one out of six residents physician's report (R2) was not updated as stated per regulations, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/19/2023
	Plan of Correction
1 2 3 4	Administrator agreed to send self certification to CCL that LIC602s have been updated by POC due date. LPA will conduct case management ro review.

Type B

Section Cited

CCR

87463(c)

Reappraisals

(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation and record review the licensee did not comply with the section cited above in five out of six residents' (R1, R2, R3, R4 & R5) care plans were not updated within the last 12 months, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/19/2023
	Plan of Correction
1 2 3 4	Administrator agreed to send self certification to CCL that care plans have been updated by POC due date. LPA will conduct case management ro review.

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: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

LIC809 (FAS) - (06/04)

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