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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803441
Report Date: 08/06/2024
Date Signed: 08/06/2024 02:07:24 PM


Document Has Been Signed on 08/06/2024 02:07 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:
(707) 559-3173
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY:6CENSUS: 6DATE:
08/06/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Kelly Sturgeon, AdministratorTIME COMPLETED:
02:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Hansen arrived unannounced at facility for the purpose of conducting a Case Management regarding a medication error. LPA met with Administrator Kelly Sturgeon.

LPA is following up regarding a self-reported Incident Report received by Community Care Licensing (CCL) on 7/30/2024 of a medication error. The error occurred at morning medication pass on 7/29/2024 while employee was dispensing medication. Caregiver inadvertently gave resident (R1) another resident’s medications during medication passing Regulation 87465(a)(4). (See LIC809-D). Hospice Dr. & pharmacy contacted regarding medications. R1 monitored with only signs of dizziness. Prescribing physician and responsible party were notified of medication error. Review of in-person (6 hr) training for medication administration was provided to caregiver on 7/30/2024.

LPA was provided medication training documents.

Appeal of Rights Given.



The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/06/2024
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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Document Has Been Signed on 08/06/2024 02:07 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 PLACE
FACILITY NUMBER: 496803441

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/07/2024
Section Cited
CCR
87465(a)(4)

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87465 Incidental Medical and Dental Care(a) A plan... shall be developed... The plan shall... provide for assistance in obtaining such care, by compliance with the following:(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced.by.
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Facility has provided in service Medication Training. POC cleared at visit.
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Based on document review and interview with Administrator, Licensee did not comply with the section cited above. R1 did not receive medication as prescribed due to caregiver not wearing glasses and giving R1 another residents medication. This poses an immediate health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 08/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/06/2024
LIC809 (FAS) - (06/04)
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