496803346-12-6-2024-21-AS-MCUA-DBPRHN-20241206120236

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803346
Report Date: 12/06/2024
Date Signed: 12/06/2024 12:02:52 PM

Document Has Been Signed on 12/06/2024 12:02 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/ DIRECTOR:	STURGEON, KELLY J.		FACILITY TYPE:	740
ADDRESS:	621 ELY BLVD. S.		TELEPHONE:	(707) 559-5062
CITY:	PETALUMA	STATE: CA	ZIP CODE:	94954
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	12/06/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:48 AM
MET WITH:	Kelly Sturgeon (Licensee)		TIME VISIT/ INSPECTION COMPLETED:	12:17 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 (LPAs) Cuadra and Frank arrived unannounced to conduct an annual required – 1 yr. visit of the facility and met with Licensee/Administrator Kelly Sturgeon. There are residents receiving hospice services and diagnostic of dementia. Annual fees are current. LPAs/Licensee toured the facility at 9:30 AM, the facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Exits were equipped with auditory devices and all auditory devices were working properly. Window screen located at the side of the facility needed to be repaired (technical advisory issued). Fire Extinguisher was found to be last charged on March 2024. Smoke detectors and carbon monoxide detectors were found to be operational during the visit. Last disaster drills have been conducted quarterly with the last one being conducted on 11/13/24. Hot water temperature measured 110.8 and 111.4, which is within Title 22 regulation. There was a sufficient supply of both perishable and nonperishable food as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations. Toxins are stored in a locked cabinet in the kitchen. There was a supply of cleaners, hygiene products and paper products available for residents. The bathrooms designated for residents at the facility were supplied with paper towels and hand soap dispensers. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom shower. All bedrooms have lighting & appropriate furnishings. However, during facility tour LPAs/Licensee observed one out of six resident's rooms needed a chair (technical advisory issued). LPAs have a discussion with the Licensee regarding the importance to have a chair available in resident's room. Contact information was reviewed. Required postings were observed. The facility does not handle cash resources. Continued on LIC809C...

Bethany Moellers	TELEPHONE: (707) 588-5040
Marisol Cuadra	TELEPHONE: (707) 588-5078
	DATE: 12/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024

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: 12/06/2024

NARRATIVE

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Continued from LIC809...

LPAs initiated file review at 10:30am. Six resident's files and three staff files were reviewed. All residents have current medical assessments and care plans. All staff have required training hours complete and 1st aid/CPR certificates updated. Administrator certificate for Administrator Kelly Sturgeon # 6023921740 expires on 1/5/2025. A spot check of residents' (R1) medication conducted by LPA's revealed Tylenol 8hr 650mg expired on 3/2024. Licensee discarded expired medication.

Licensee agreed to submit updates of the following documents by 12/13/24: LIC 308 Designated of facility responsibility, LIC 500 Personnel Summary, LIC 610 Emergency Disaster Plan – if changes, copy of Certificate of Liability Insurance and proof of control of property.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview was conducted with Licensee and a copy of this report was given.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/06/2024 12:02 PM - 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: 12/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Incidental Medical and Dental Care Services

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's/Licensee observation, interview and record review, the licensee did not comply with the section cited above in one resident's (R1) medication Tylenol 650mg expired on March 2024 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/13/2024
	Plan of Correction
1 2 3 4	Licensee discarded expired medication immediately. Licensee will submit a written plan addressing how they will ensure PRN medication will be reviewed periodically to discard any expired medication by POC due date 12/13/24 to clear the citation.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Bethany Moellers	TELEPHONE: (707) 588-5040
Marisol Cuadra	TELEPHONE: (707) 588-5078
	DATE: 12/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024

LIC809 (FAS) - (06/04)

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