496803441-5-30-2023-21-AS-SHAN-CSBQV4-20230530122942

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803441
Report Date: 05/30/2023
Date Signed: 05/30/2023 12:29:50 PM

Document Has Been Signed on 05/30/2023 12:29 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 PLACE		FACILITY NUMBER:	496803441
ADMINISTRATOR:	STURGEON, KELLY		FACILITY TYPE:	740
ADDRESS:	617 ELY BOULEVARD SOUTH		TELEPHONE:	(707) 559-3173
CITY:	PETALUMA	STATE: CA	ZIP CODE:	94954
CAPACITY:	6	CENSUS: 5	DATE:	05/30/2023
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	08:10 AM
MET WITH:	Kelly Sturgeon, Administrator		TIME COMPLETED:	12:45 PM

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License Program Analyst (LPA) Hansen arrived unannounced to conduct an annual required – 1 yr. inspection of the facility. Kelly Sturgeon – licensee/administrator was contacted by staff and arrived during the visit. There is a total of 5 residents and 3 with a diagnostic of dementia. There are 2 residents currently on Hospice.

LPA toured the facility on 5/30/2023 at 8:15 AM with staff Yuri Gonzales; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Exits were equipped with auditory devices. Fire Extinguisher was found to be last charged on 3/15/2023 at the time of the visit. Smoke detectors and carbon monoxide detectors were found to be operational during the visit. Hot water temperature measured between 105.9 degrees F and 107.6 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 2 of 2 resident’s bathrooms while touring facility on 5/30/2023. The facility serves residents with dementia and has a plan of operation for special care and programming. 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 on this day at the time of the visit. Toxins are stored in a locked cabinet in the kitchen. Kitchen drawer containing sharps has stuck lock (see LIC9102 Advisory Notes).

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.

A review of five resident & three staff records as well as two resident’s medications was conducted. LPA reviewed resident’s files at 9:00 AM and learned that 5 of 5 residents have an updated re-appraisals/needs & care plans and physician’s assessments (LIC 602A).

Continued on LIC809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023

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 PLACE	FACILITY NUMBER: 496803441
	VISIT DATE: 05/30/2023

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LPA reviewed a sample of staff records at 9:45 AM 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 2023 are on file. LPA was presented with proof of CPR & 1^st Aid certification for staff that files were reviewed. Kelly Sturgeon Administrator Certificate # 6023921740 expires on 1/5/2023 LPA was provided proof of recertification received by department on 1/31/2023, still pending.

Medications were centrally stored in locked cabinet in the facility office area between kitchen and dining room. The Medications of 2 out of 2 residents were found to be given according to physicians’ directions on 5/30/2023 at 10:30 AM. Centrally Stored Medication Record (CSMR) of 2 out of 2 residents were found to be complete and accurate.

Disaster Drills are conducted quarterly with the last one being conducted on 5/17/2023.

There were no deficiencies cited at this time.

LPA Hansen is requesting Licensee to update the following documents and submit to CCL by 6/13/2023:

LIC 308 Designated
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Resident’s
Copy of Administrator Certificate
Copy of Certificate of Liability Insurance

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023

LIC809 (FAS) - (06/04)

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