496803346-10-6-2022-21-AS-SHAN-CJXU3M-20221006151346

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803346
Report Date: 10/06/2022
Date Signed: 10/06/2022 03:14:02 PM

Document Has Been Signed on 10/06/2022 03:14 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:	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:	5	CENSUS: 5	DATE:	10/06/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:55 PM
MET WITH:	Kelly Sturgeon - Administrator		TIME COMPLETED:	03:15 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) Hansen conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and was welcome by staff Danielle Nunez. Licensee Kelly Sturgeon conducted the visit. Facility has 5 residents, all with dementia, without any on hospice care at the time of visit. During facility tour on 10/6/2022 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 3/7/2022 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 residents. Residents' bedrooms have lighting & appropriate furnishings. Water temperature in resident's bathrooms measured 113.5 degrees F and 114.6 degrees F which are within acceptable range of 105 to 120 degrees F. Residents’ medications are centrally stored and locked in the office area by dining room. Facility has a 30-day supply of medication for residents. All staff had masks on during this visit. Facility has activities for residents such as group working exercises, reading word game, and other activity plans for residents during the day. Disaster Drills have been conducted quarterly with the last one being conducted this morning, a fire drill was conducted for both NOC and PM shifts, 10/6/2022. Continue LIC 809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2022

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: CREEKSIDE COTTAGE	FACILITY NUMBER: 496803346
	VISIT DATE: 10/06/2022

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Infection Control:
Facility has submitted a mitigation program plan and infection control plan that has been approved. Posters have been placed at facility and entrance has 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.

In addition, facility has a designated area for visitors which are being allowed for scheduled visits. Residents also have 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.

LPA Hansen reviewed Licensing Information System (LIS) with staff who stated that is corrected and updated at this time. LPA advised facility to contact Local County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility.

LPA was presented with proof of current CPR & 1^st Aid certification for staff.

Administrator Certificate is for Kelly Sturgeon # 6023921740 Exp. 1/5/2023
All staff have received COVID booster vaccinations.

No deficiencies cited during todays inspection

LPA Hansen is requesting Administrator to update and submit the following documents by 10/27/2022:

LIC 308 Designated

Articles of Corporation

LIC 500 Personnel Summary

LIC 610 Emergency Disaster Plan

LIC 610E-S Supplemental Emergency Disaster Plan for RCFE

LIC 9020 Register of Facility Client’s/Resident’s

Copy of Administrator Certificate

Copy of Certificate of Liability Insurance

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2022

LIC809 (FAS) - (06/04)

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