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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803441
Report Date: 06/07/2022
Date Signed: 06/07/2022 01:36:01 PM

Document Has Been Signed on 06/07/2022 01:36 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 PLACEFACILITY NUMBER:
496803441
ADMINISTRATOR:STURGEON, KELLYFACILITY TYPE:
740
ADDRESS:617 ELY BOULEVARD SOUTHTELEPHONE:
7075593173
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY: 6CENSUS: 6DATE:
06/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Kelly Sturgeon-AdministratorTIME COMPLETED:
01:36 PM
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Licensing Program Analyst (LPA) Shannan Hansen conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and was welcome by staff Carmen. Administrator was contacted and arrived 15 minutes later for the visit. Facility has 6 residents with 2 residents bedridden as one just graduated out of hospice, and 1 resident on Hospice.

LPA arrived at the facility and had temperature checked and logged into visitor’s binder. During facility tour on 6/07/2022 at 9:45 AM 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 3/7/22 at the time of the visit. Smoke Detectors & Carbon monoxide detector was found to be operational during the visit. There was a supply of both perishable and nonperishable foods, groceries are delivered every Tuesday afternoon. 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 residents at the facility. Hot water temperatures measured 107 degrees F. & 109 degrees F within Title 22 acceptable regulations 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. Facility has activities for residents: group working exercises, reading word games, table bowling, flower arranging, and story reading for residents during the week. Disaster Drills have been conducted quarterly with the last being May 17, 2022.

Continue on LIC 809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/07/2022
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 PLACE
FACILITY NUMBER: 496803441
VISIT DATE: 06/07/2022
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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. All staff had masks on during this visit. All staff had PPE training required on file and have received N-95 fit testing. All staff eligible have received their COVID -19 Booster shots.

LPA reviewed Licensing Information System (LIS) with Administrator who stated that is correct 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 viewed Administrator Certificate for Kelly Sturgeon #6023921740 Exp. 1/5/2023.

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

LPA reviewed new PIN 22-18-ASC regarding Infection Control Plan due in CCL by 6/31/2022

There were no deficiencies cited at this time.



LPA Hansen is requesting Licensee to update and submit the following documents by 6/24/2022 to SRRO:

LIC 308 Designated

LIC 500 Personnel Summary

LIC 610 Emergency Disaster Plan

LIC 610E Supplemental Emergency Disaster Plan for RCFE

LIC 9020 Register of Facility Resident’s

Copy of Administrator Certificate

Proof of Liability Insurance

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2022
LIC809 (FAS) - (06/04)
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