496803346-7-22-2021-21-AS-CFGS-C56V7L-20210722161120

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803346
Report Date: 07/22/2021
Date Signed: 07/22/2021 04:11:33 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME:	CREEKSIDE COTTAGE		FACILITY NUMBER:	496803346
ADMINISTRATOR:	STURGEON, KELLY J.		FACILITY TYPE:	740
ADDRESS:	621 ELY BLVD. S.		TELEPHONE:	(707) 559-5062
CITY:	PETALUMA	STATE: CA	ZIP CODE:	94954
CAPACITY:	6	CENSUS: 5	DATE:	07/22/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Kelly Sturgeon - Licensee/Administrator		TIME COMPLETED:	10:52 AM

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 (LPAs) Fernandes-Goes and Hansen conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and was welcome by staff Josefina. Licensee was contacted and arrived during the visit. Facility has 5 residents with 1 resident under hospice care. Facility has activities for residents such as group working exercises, reading word game, and other activity plans for residents during the day. LPAs arrived at the facility and had their temperatures checked and logged into visitor’s binder. During facility tour on 7/22/2021 with staff Josefina first and then with Licensee/Admin Kelly Sturgeon, facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 03/2021 at the time of the visit. Smoke Detectors & Carbon monoxide detector was found to be operational during the visit. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored in a locked closet by the laundry/resident’s bathroom. Dangerous items were stored inaccessible to residents. There was a supply of cleaners, hygiene products and paper products available for clients. Residents' bedrooms have lighting & appropriate furnishings, and mattress pads are available for clients at the facility. Hot water temperatures measured degrees F within Title 22 acceptable regulations of 105 to 120 degrees F. Infection Control: Facility has submitted a mitigation program plan that has been approved. Posters have been placed at facility and entrance has small table with hand sanitizer and other items designated for visitors and staff before coming into work. Facility has PPE supply stored in outside shed, office, and bathroom. Facility has hired or admitted anyone new since COVID-19. Continue LIC 809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: CREEKSIDE COTTAGE	FACILITY NUMBER: 496803346
	VISIT DATE: 07/22/2021

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
26
27
28
29
30
31
32

Residents’ medications are stored and locked in the office area by dining room. Facility has a 30-day supply of medication for clients. Residents aren’t wearing masks inside the facility, however; licensee/admin stated that they are able to wear masks when going on outings. All staff had masks on during this visit.

In addition, facility has a designated area for visitors which are being allowed for scheduled visits. Residents have also available Zoom, Facetime, and telephone calls when contacting with family members and others. Staff had all PPE training required on file and have obtained N-95 fit testing.

LPAs advised facility to contact Local County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Disaster Drills have been conducted quarterly with the last one being conducted on 5/21/2021.

There were no deficiencies cited at this time.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021

LIC809 (FAS) - (06/04)

Page: 2 of 4