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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803346
Report Date: 12/30/2021
Date Signed: 12/30/2021 03:19:57 PM

Document Has Been Signed on 12/30/2021 03:19 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:CREEKSIDE COTTAGEFACILITY NUMBER:
496803346
ADMINISTRATOR:STURGEON, KELLY J.FACILITY TYPE:
740
ADDRESS:621 ELY BLVD. S.TELEPHONE:
(707) 559-5062
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY: 5CENSUS: 2DATE:
12/30/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:01 PM
MET WITH:Staff Daniel Nunez and Spoke with Administrator Kelly Sturgeon on phone TIME COMPLETED:
03:20 PM
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On 12/30/2021 at approximately 2:05 PM Licensing Program Analyst (LPA) Hansen arrived unannounced to conduct a Case Management inspection and met with Staff Danielle as Administrator was out. Staff called Administrator Kelly Sturgeon who confirmed staff can sign for her. LPA was temperature checked and logged on folder for all visitors.

CCL received incident report that occurred 12/28/21 of a Resident (R1) was admitted to the facility on 12/10/21 with a primary diagnosis of stroke with aphasia and right sided weakness along with dementia. R1 is on Hospice with continuum. R1 has recently had shortness of breath with primary care physician thinks it is very likely lung cancer. R1 had previously been on antipsychotic medications but wife requested doctor to decrease so they did.

Incident of 12/28/21 at approximately 3am R1 was very restless and went wandering into other residents’ room. Staff assisted and found R1 to appear highly agitated and confused when R1 punched staff in the ribs and shoulder. Staff required medical attention for contusions to left ribs and left shoulder.

LPA spoke on the phone with Administrator when LPA arrived at facility to find out last night (12/29/21) while R1 was again up in the middle of the night Administrator found R1 and R1 grabbed Admins arm and twisted it and pulled Admin to the ground. Administrator was able to safely get up and get help.

Administrator explained R1 has become extremely strong and been constantly trying to elope.

This morning (12/30/21) R1 grabbed staff’s hand and squeezed it as hard as R1 could. Staff’s arm is now swollen and bruised. Administrator immediately called hospice nurse who instructed to call 911. R1’s wife arrived along with police and decided to have wife take R1 to Santa Rosa Kaiser as hospice nurse followed. Hospice nurse called ahead to make sure R1 got admitted.

R1 was admitted and will be assed and not returning to the facility as his needs are beyond their care ability.

No deficiencies cited during this inspection.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 12/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/30/2021
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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