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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803282
Report Date: 08/15/2024
Date Signed: 08/15/2024 03:47:18 PM

Document Has Been Signed on 08/15/2024 03:47 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:SPRING CREEK LODGEFACILITY NUMBER:
496803282
ADMINISTRATOR/
DIRECTOR:		ALCONES, LILYFACILITY TYPE:
740
ADDRESS:3650 SPRING CREEK DRIVETELEPHONE:
(707) 523-3255
CITY:SANTA ROSASTATE: CAZIP CODE:
95405
CAPACITY: 6CENSUS: 6DATE:
08/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:03 AM
MET WITH:Lily Alcones, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:43 PM
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Licensing Program Analysts (LPAs) Christi Coppo and Marisol Cuadra arrived unannounced to conduct a required Annual inspection and was greeted by caregiver. Administrator Lily Alcones arrived later. Facility contact information was reviewed.

At approximately 9:15am LPAs toured the building and grounds. The facility was found to be at a comfortable temperature. LPAs observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered. Kitchen drawer with sharp knives locked. Cabinets containing cleaning supplies locked.

All bedrooms were equipped with lighting, night stand, and chest of drawers. Extra hygiene products and linens were available. Resident bathroom had required bath mat and grab bar. Water temperature in sink accessible to residents in care measured at 158 degrees F in the kitchen, LPA could not get a hot water reading in the bathroom across from room six, the water never got hot after running the water for 4 minutes which is not within the allowable range of 105 to 120 degrees F (deficiency cited, see 809D).

LPAs observed window in back bathroom in hallway to be broken, does not stay up when lifted, will not stay open. LPAs observed hole in wall on left side of the refrigerator. Backyard deck in disrepair, handrails broken and base of handrails cracked. Fence in backyard also in disrepair. Planks separated from fence with nails exposed. Large fence surrounding the perimeter of the facility is also in disrepair, boards separating from fence and nails exposed. Vents on side of house have gaps and black film substance. Per LPAs conversation with Admin they agree to repair. LPAs reviewed fire clearance facility sketch and observed exit gate to be identified as an emergency exit. LPAs observed exit gate to be broken, does not close or open all the way. However, because this is identified as a fire clearance exit, it must offer access for residents as an escape in emergency situations.(deficiency cited, see 809D).

Continued on 809C...
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE: DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/15/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: SPRING CREEK LODGE
FACILITY NUMBER: 496803282
VISIT DATE: 08/15/2024
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Continued from 809...

LPAs discussed with Admin deck and kitchen, Admin indicated that they will be redoing the deck and remodeling the kitchen, but not changing the structure of the facility. LPAs advised that if they do change the structure of the facility they must obtain the proper and required permits first and give notice to CCL prior to any initiation of construction.

Fire extinguishers were last inspected 9/15/2023. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Facility’s last quarterly disaster drills were conducted on 6/27/2024. Facility has a backup generator for use during a power outage.

At approximately 10:30am LPAs conducted review of 5 staff records. All required documentation present. Admin indicated they have three full time staff, one of which is staff (S1). However, (S1) did not have fingerprint clearance and not associated to the facility, but per Admin has been working here for about 3 months (deficiency cited, see 809D and civil penalty assessed in the amount of $500 LIC421BG).

At approximately 11:30am LPAs conducted a review of 6 resident records. Resident (R1) is indicated as bedridden on their physician's report. However, facility does not have fire clearance for bedridden residents. Admin unable to produce proof of notification to the Santa Rosa Fire Dept. LPAs and Admin discussed bedridden status on current physician's report, due to two different status being marked, Admin agreed to get updated physician's report clarifying ambulatory status of resident R1 (deficiency cited, see 809D).

At approximately 12:00pm LPA and Admin conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet. No deficiencies

Lily Alcones Administrator Certificate 7003673740 expires 8/31/2024. All fees are current as of this time.



LPAs and Administrator discussed facility's Infection Control Plan and Emergency Disaster plan. No new updates.

Continued on 809C(2)...
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: SPRING CREEK LODGE
FACILITY NUMBER: 496803282
VISIT DATE: 08/15/2024
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Continued from 809C...

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC500- Personnel Report
LIC308- Designation of Responsibility
Liability Insurance

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Licensee. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with Administrator and a copy of this report was given

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 08/15/2024 03:47 PM - It Cannot Be Edited


Created By: Christi Coppo On 08/15/2024 at 12:28 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: SPRING CREEK LODGE
FACILITY NUMBER: 496803282

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPAs and Admin observation, interview, and record review, the licensee did not comply with the section cited above in that staff (S1) did not have fingerprint clearance and not associated to the facilitywhich poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2024
Plan of Correction
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2
3
4
Facility to submit LIC9098 self-certifying that S1 will not be present in any capacity at facility until S1 has fingerprint clearance and is associated to the facility.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Victoria Bertozzi
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2024


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 08/15/2024 03:47 PM - It Cannot Be Edited


Created By: Christi Coppo On 08/15/2024 at 12:28 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: SPRING CREEK LODGE
FACILITY NUMBER: 496803282

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs and Admin observation, the licensee did not comply with the section cited above in that LPAs observed window in back bathroom in hallway to be broken, does not stay up when lifted, will not stay open. LPAs observed hole in wall on left side of the refrigerator. Backyard deck in disrepair, handrails broken and base of handrails cracked. Fence in backyard also in disrepair. Planks separated from fence with nails exposed. Large fence surrounding the perimeter of the facility is also in disrepair, boards separating from fence and nails exposed. Vents on side of house have gaps and black film substance. Per LPAs conversation with Admin they agree to repair, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/05/2024
Plan of Correction
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Facility to submit pictures of repaired fences, deck handrails, side yard gate, bathroom window, vent gaps on side of house repaired with black substance removed, and hole in wall in kitchen repaired by plan of correction due date.
Type B
Section Cited
CCR
87303(e)(3)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation, the licensee did not comply with the section cited above in that water temperature in sink accessible to residents in care measured at 158 degrees F in the kitchen, LPA could not get a hot water reading in the bathroom across from room six, the water never got hot after running the water for four minutes which is not within the allowable range of 105 to 120 degrees F, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/29/2024
Plan of Correction
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Facility to submit two week water log of water temperature readings with readings of water within regulation. Water log to be submitted with pictures of temperature with therometer reading present in picture. Water log and pictures to be submitted to CCL by plan of ocrrection due date.
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:Victoria Bertozzi
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2024


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 08/15/2024 03:47 PM - It Cannot Be Edited


Created By: Christi Coppo On 08/15/2024 at 12:28 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: SPRING CREEK LODGE
FACILITY NUMBER: 496803282

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.72(f)
Levels of Care
(f) Notwithstanding the length of stay of a bedridden resident, every facility admitting or retaining a bedridden resident, as defined in this section, shall, within 48 hours of the resident’s admission or retention in the facility, notify the local fire authority with jurisdiction in the bedridden resident’s location of the estimated length of time the resident will retain his or her bedridden status in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on LPAs and Admin record review, the licensee did not comply with the section cited above in that R1 is indicated as bedridden on their physician's report. However, facility does not have fire clearance for beridden residents. Admin unable to produce proof of notification to the Santa Rosa Fire Dept, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/29/2024
Plan of Correction
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3
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Facility to submit either updated physician's report clarifying ambulatory status of resident R1 as not bedridden or facility to provide proof of fax notification to Santa Rosa Fire Dept notifying them of the bedridden status of R1 by plan of correction due date.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
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:Victoria Bertozzi
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2024


LIC809 (FAS) - (06/04)
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