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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803346
Report Date: 10/13/2023
Date Signed: 10/13/2023 11:00:59 AM


Document Has Been Signed on 10/13/2023 11:00 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:
10/13/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
08:43 AM
MET WITH:Kelly Sturgeon, Licensee/AdministratorTIME COMPLETED:
11:10 AM
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License Program Analyst (LPA) Shannan Hansen arrived at 8:15 AM to complete an unannounced annual inspection and was welcomed by staff Alondra Amezcua who contacted Licensee/Administrator Kelly Sturgeon who arrived shortly after. There is a total of 6 residents, all with a diagnostic of dementia, with 3 on hospice.

LPA continued inspection with a review of six resident & five staff records as well as two resident’s medications conducted. LPA reviewed resident’s files at 8:40 AM on 10/13/2023 and learned that 6 of 6 residents have an updated re-appraisals/needs & care plans and updated physician’s assessments (LIC 602A).

Medications were centrally stored in locked cabinet in the facility office area between kitchen and dining room at 10:00 AM on 10/13/2023. The Medications of 2 out of 2 residents were found to be given according to physicians’ directions on 10/13/2023 at 10:15 AM. Centrally Stored Medication Record (CSMR) of 2 out of 2 residents were found to be complete and accurate.

LPA reviewed a sample of staff records at 9:30 AM on 10/13/2023 and learned that all facility staff present and a sample of other individuals who require caregiver background checks have received criminal record clearances or exemptions. Direct care staff annual training requirements for 2022/2023 are on file. LPA was presented with proof of CPR & 1st Aid certification for staff that files were reviewed although 1 staff only had CPR/AED although is signed up for First Aid today (see LIC 9102 Advisory Notes). LPA reviewed health records for staff and observed 1 staff (S1) not having proof of TB in file (see LIC 9102 Advisory Notes) Administrator sending. Kelly Sturgeon Administrator Certificate # 6023921740 expires on 1/5/2025.

Continue LIC 809-C

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 10/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2023
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: CREEKSIDE COTTAGE
FACILITY NUMBER: 496803346
VISIT DATE: 10/13/2023
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No deficiencies cited during today's inspection.

LPA Hansen is requesting Licensee to update the following documents by 10/31/2023:

LIC 308 Designated
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan – if changes
LIC 9020 Register of Facility Client’s/Resident’s
Copy of Administrator Certificate
Copy of Certificate of Liability Insurance
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2023
LIC809 (FAS) - (06/04)
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