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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803441
Report Date: 07/22/2021
Date Signed: 07/22/2021 01:48:55 PM

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 PLACEFACILITY NUMBER:
496803441
ADMINISTRATOR:STURGEON, KELLYFACILITY TYPE:
740
ADDRESS:617 ELY BOULEVARD SOUTHTELEPHONE:
(707) 559-3173
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY:6CENSUS: 6DATE:
07/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Administrator Kelly SturgeonTIME COMPLETED:
01:47 PM
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Licensing Program Analyst (LPA) Shannan Hansen & Licensing Program Manager (LPM) Kim Mota conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and was welcome by staff Danielle. Licensee was contacted and arrived during the visit. Facility has 6 residents with 1 resident bedridden for the last 9 months. Facility has activities for residents such as group working exercises, reading word game, and other activity plans for residents during the day.

LPA & LPM arrived at the facility and had their temperatures checked and logged into visitor’s binder. During facility tour on 7/22/2021 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 03/2021 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, and mattress pads are available for clients at the facility. Hot water temperatures measured 106.6 degrees F. & 108.1 degrees F within Title 22 acceptable regulations of 105 to 120 degrees F.

Infection Control:
Facility has submitted a mitigation program plan that has been approved. Posters have been placed at facility and entrance has small table with 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. Facility has hired and admitted new residence since COVID-19 who were tested in advance. Residents’ medications are stored and locked in the office area by dining room. Facility has a 30-day supply of medication for clients. Residents aren’t wearing masks inside the facility, however; licensee/admin stated that they are able to wear masks when going on outings. All staff had masks on during this visit.

Continue LIC 809-C.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-1410
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
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 PLACE
FACILITY NUMBER: 496803441
VISIT DATE: 07/22/2021
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LPA Hansen reviewed Licensing Information System (LIS) with staff who stated that is corrected and updated at this time. In addition, LPA advised facility to contact Local County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility.
In addition, facility has a designated area for visitors which are being allowed for scheduled visits. Residents have also 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.

There were no deficiencies cited at this time
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-1410
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021
LIC809 (FAS) - (06/04)
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