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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803441
Report Date: 08/31/2023
Date Signed: 08/31/2023 09:37:00 AM


Document Has Been Signed on 08/31/2023 09:37 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 PLACEFACILITY NUMBER:
496803441
ADMINISTRATOR:STURGEON, KELLYFACILITY TYPE:
740
ADDRESS:617 ELY BOULEVARD SOUTHTELEPHONE:
(707) 559-3173
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY:6CENSUS: 4DATE:
08/31/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Kelly Sturgeon, AdministratorTIME COMPLETED:
09:40 AM
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License Program Analyst (LPA) Hansen arrived unannounced to conduct an annual required – 1 yr. inspection of the facility. Kelly Sturgeon, Administrator was contacted by staff and arrived during the visit. There is a total of 4 residents and 3 with a diagnostic of dementia. There are no residents currently on Hospice.

LPA is conducting a Healthy and Safety inspection/follow up. The purpose is to follow up on annual conducted on 5/30/2023 due to system date inconsistency. LPA toured the facility and made observations.

There were no deficiencies cited during today’s visit.

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2023
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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