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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803282
Report Date: 07/19/2022
Date Signed: 07/19/2022 04:20:04 PM

Document Has Been Signed on 07/19/2022 04:20 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: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:
07/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Licensee Lily Alcones & Administrator Arthur AlconesTIME COMPLETED:
03:39 PM
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Licensing Program Analysts (LPA) Hansen conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and was welcomed by Licensee Lily Alcones. Administrator Arthur Alcones arrived shortly after. There were 6 residents present at the facility with 2 on hospice. LPA had computer issues and had to leave without obtaining signature. LPA emailed documents for signature of visit.

LPA toured the facility at 1:10 PM with Licensee Lily Alcones. During tour on 7/19/2022 facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers were found to be last charged on 9/15/2021 at the time of the visit. Smoke Detectors & Carbon monoxide detectors were found to be operational during the visit. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Facility staff understands that food stored in the kitchen refrigerator must be properly stored as per regulations. Hot water temperature measured 105.6 degrees F and 106.7 degrees F within acceptable regulations of 105 to 120 degrees F in 2 of 2 resident’s bathroom faucets. There was a supply of cleaners, hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings. Toxins are secured and inaccessible in locked garage cabinets.

During the inspection, LPA observed individual (I1) to be present and providing care at the facility. LPA verified in the facility Personal Report/Roster in Guardian that I1 was not associated to Spring Creek Lodge. Administrator stated the required paperwork to associate I1 to the facility had been filled out and believed was associated. LPA contacted the Rohnert Park Regional Office and confirmed I1 is not associated to Spring Creek Lodge but is background cleared and associated to their other facility Sleepy Hollow Assisted Living. Administrator stated I1 has been working at Spring Creek Lodge for 4 months. LPA confirmed with the Rohnert Park Regional Office that I1 has fingerprint clearance but is not associated as required.

Continue LIC 809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 07/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/19/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
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: SPRING CREEK LODGE
FACILITY NUMBER: 496803282
VISIT DATE: 07/19/2022
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LPA explained prior to staff working or volunteering, they are required to be fingerprint cleared and associated to the facility. LPA explained Community Care Licensing (CCL) requirements and provided the personal ID numbers & forms needed to associate I1. Administrator stated the facility faxed the required forms during the inspection and will contact CCL to verify the individual is associated to the facility. Administrator stated they understood CCL's requirements and prior to anyone working, providing care, volunteering, or residing at Spring Creek Lodge, the individual must obtain a fingerprint clearance and be associated to the facility. Prior to end of business day Administrator confirmed I1 was associated to facility, LPA confirmed with CCL association.

Infection Control:
Facility has submitted a mitigation program plan that was approved, and an Infection Control Plan has been submitted. Posters have been placed at facility. Facility has PPE supply stored in garage. Residents’ medications are centrally stored and locked in the office cabinet. Facility has a 30-day supply of medication for residents. Residents do not wear masks inside the facility. Facility offers activities of board games, music, & socializing on the back porch when it is not too hot for the residents.

In addition, facility has a designated area for visitors in the backyard, living room, and/or in the bedrooms when possible. Residents have also available Zoom and telephone calls when contacting with family members and others. Staff had all PPE training required on file and all have been N-95 fit tested.



LPA reviewed Licensing Information System (LIS) with licensee who stated that is correct and updated at this time. In addition, LPA advised facility to contact County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility.

Continue on LIC 809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2022
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: SPRING CREEK LODGE
FACILITY NUMBER: 496803282
VISIT DATE: 07/19/2022
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LPA was presented with proof of CPR & 1st Aid certification for staff which files were reviewed.
Administrator Certificate’s for Lily Alcones # 6013178740 Exp. 3/9/2024 & Arthur Alcones #6032230740 Exp. 8/23/2022

All staff have received COVID booster vaccinations.

No deficiencies cited during this inspection

LPA Hansen is requesting Licensee to update and submit the following documents by 8/2/2022 to SRRO:

LIC 308 Designated

LIC 500 Personnel Summary

LIC 610 Emergency Disaster Plan

LIC 9020 Register of Facility Resident’s

Copy of Administrator Certificate

Proof of Liability Insurance

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2022
LIC809 (FAS) - (06/04)
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