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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200521
Report Date: 12/14/2022
Date Signed: 12/14/2022 10:52:42 AM

Document Has Been Signed on 12/14/2022 10:52 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:CREEKVIEW ASSISTED LIVINGFACILITY NUMBER:
019200521
ADMINISTRATOR:PATRICK D. MCELROYFACILITY TYPE:
740
ADDRESS:2900 STONERIDGE DRIVETELEPHONE:
(925) 353-5717
CITY:PLEASANTONSTATE: CAZIP CODE:
94588
CAPACITY: 136CENSUS: 69DATE:
12/14/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:19 AM
MET WITH:Patrick D. Mcelroy, AdminstratorTIME COMPLETED:
11:00 AM
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On 12/14/22 at 10:19AM, Licensing Program Analyst (LPA) Kelly Nguyen conducted an unannounced case management visit as a result of receiving SOC341 self-reported incidents dated 10/ 28/22 submitted to CCLD regarding staff stuck a resident hand. LPA explained the purpose of the visit with Patrick Administrator (ADM). Routine COVID-19 symptom checks were done to LPA by staff wearing face mask at the front entrance.

LPA interviewed Administrator, reviewed training documents, and video footage of the incident indicating S1 have been fully trained on staff personal rights. R1 son spoke with ADM/ review the footage of the incident, and states that he doesn’t have any question or concern regarding the incident.

No deficiencies cited during visit. Exit interview conducted and a copy of the report is provided to Administrator.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 12/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/14/2022
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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