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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803282
Report Date: 08/04/2021
Date Signed: 08/04/2021 10:17:33 AM

Document Has Been Signed on 08/04/2021 10:17 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:SPRING CREEK LODGEFACILITY NUMBER:
496803282
ADMINISTRATOR:ALCONES, LILYFACILITY TYPE:
740
ADDRESS:3650 SPRING CREEK DRIVETELEPHONE:
(707) 523-3255
CITY:SANTA ROSASTATE: CAZIP CODE:
95405
CAPACITY: 6CENSUS: 6DATE:
08/04/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Licensee/Admistrator, Lily & Arthur AlconesTIME COMPLETED:
10:30 AM
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Licensing Program Analysts (LPA), Erik Gonzalez Campos arrived unannounced to conduct a Required - 1 Year inspection at approximately 8:45 AM, and met with licensee/administrator Arthur and Lily Alcones. The inspection is focused on the Infection Control procedures and practices of this facility. LPA was initially greeted by staff, licensee/administrator arrived shortly.

Upon entry LPA was screened for COVID symptoms and asked to sign in by staff. At primary entrance LPA observed visitor sign-in sheet. LPA conducted walk through of the facility with licensee/administrator and observed COVID postings throughout. Mitigation plan was received and reviewed during visit.

Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is kept throughout the facility except for in rooms with residents with dementia. Per administrator, updated infection control guidelines and PINs are communicated to responsible parties verbally. Staff have completed Personal Protective Equipment (PPE) and infection control training through Kaiser. Staff have been N95 fit tested. High touch surface areas are disinfected daily. Due to current facility census, residents could isolate in their own rooms if they became ill. LPA confirmed facility has necessary PPE equipment and supplies to support a resident in isolation.

Residents' emergency contact information has been updated and administrator confirmed staff are familiar with 911 procedures and protocols. Toxins are secured and inaccessible in locked garage cabinets. A 30 day supply of medications are stored in locked medication room, making them inaccessible to residents. The facility has a sufficient supply of Personal Protective Equipment (PPE). Exit alarms on exit doors were working properly. Facility is conducting COVID-19 surveillance testing per CCL guidelines.

Continued on LIC 809C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Erik Gonzalez Campos
LICENSING EVALUATOR SIGNATURE: DATE: 08/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/04/2021
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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: SPRING CREEK LODGE
FACILITY NUMBER: 496803282
VISIT DATE: 08/04/2021
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Facility is allowing residents to have meals in the dining room and furniture is set up for social distancing. Common areas are also set up for social distancing. LPA and administrator discussed resident activities which include exercises and music. Visitation is primarily on outside patio area.

No deficiencies cited during this inspection
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Erik Gonzalez Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2021
LIC809 (FAS) - (06/04)
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