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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803346
Report Date: 01/12/2023
Date Signed: 01/12/2023 09:05:47 AM


Document Has Been Signed on 01/12/2023 09:05 AM - 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 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:6CENSUS: 6DATE:
01/12/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Kelly Sturgeon - AdministratorTIME COMPLETED:
09:20 AM
NARRATIVE
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Licensing Program Analyst (LPA) Hansen arrived unannounced at facility for the purpose of conducting a Case Management- incident inspection regarding a medication error. LPA met with Administrator Kelly Sturgeon.

LPA is following up regarding a self-reported Incident Report received by Community Care Licensing (CCL) on 01/06/2023 of a medication error. The error was identified on 01/02/2023 that included 8 previous errors in the past month due to pm shift staff accidentally over medicating resident on antidepressant medication. (See LIC809-D) Responsible party and prescribing physician were notified of the medication error.

Appeal of Rights Given.



The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2023
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 2


Document Has Been Signed on 01/12/2023 09:05 AM - 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: CREEKSIDE COTTAGE
FACILITY NUMBER: 496803346

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/13/2023
Section Cited

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87465(a)(5) Incidental Medical and Dental Care. A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: The licensee shall assist residents with self-administered medications as needed.
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Plan of Correction already fulfilled with training with all staff that pass medication. LPA obtained copies.
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Based off self-reported incident report and interview with Administrator, the PM care staff over medicated the resident on antidepressants. This is an immediate health, safety and personal rights risk to residents in care.
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POC cleared.

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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 MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 01/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2