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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803282
Report Date: 08/14/2025
Date Signed: 08/14/2025 02:46:37 PM

Document Has Been Signed on 08/14/2025 02:46 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/
DIRECTOR:		ALCONES, LILYFACILITY TYPE:
740
ADDRESS:3650 SPRING CREEK DRIVETELEPHONE:
(707) 523-3255
CITY:SANTA ROSASTATE: CAZIP CODE:
95405
CAPACITY: 6CENSUS: 4DATE:
08/14/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:53 AM
MET WITH:Arthur Alcones (Back up Administrator)TIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a required Annual inspection and was greeted by caregiver Edwin Taitano. Administrator Lily Alcones was in the Phillipines and staff called back up Administrator, Arthur Alcones to come to the facility. However, Mr. Alcones arrived at 10:17am. LPA requested a written plan from Licensee to address how they will ensure that back up administrator spends a reasonable amount of time in the facility, while Licensee/Administrator Lily Alcones is in the Phillipines to ensure resident's care needs will be met in case of an emergency and Community Care Licensing inspections. Facility contact information was reviewed. Annual fees are outstanding in the amount of $495.

At approximately 9:00am LPA toured the building and grounds. The facility was found to be at a comfortable temperature. All bedrooms were equipped with required furniture. Fire extinguisher charged and serviced as of December 2024. Smoke detectors and carbon monoxide were tested and operational. Auditory alarms were found operational. Last disaster drill was conducted on 7/8/25. Extra hygiene products and linens were available. LPA observed at least a two day supply of perishable and seven day supply of non-perishable food. Kitchen drawer with sharp knives locked. Cabinets containing cleaning supplies locked. Resident's bathrooms had required bath mat and grab bar, but one out of two bathrooms did not have paper towels available for residents in care (technical advisory issued).

At approximately 9:05am, LPA/staff observed a lock in the exit gate, during last annual conducted on 8/14/24, LPA reviewed fire clearance facility sketch and it was clarified with back up administrator to be an exit gate identified as an emergency exit. LPA have a conversation with back up administrator to remind them of this exit is identified as a fire clearance exit, and it must offer access for residents as an escape in emergency situations, the lock was removed by back up administrator.
Continued on 809C...
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Marisol Cuadra
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/14/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 08/14/2025
NARRATIVE
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Continued from 809...
Also, it was observed in resident's rooms cracks on the wall that needed to be repaired. Back up administrator showed LPA written communication with LPM Bertozzi dated June 2025 outlining their intentions to start a construction project where adobe clay of the foundation is settle causing the cracks on the walls. According to back up administrator, they are fully permitted to start the construction from the city of Santa Rosa to raise the foundation on the right side of the house by 4 to 6 inches, which according to the contractor it will be completely safe for the residents to stay in their rooms without a need to relocation. However, as described per the drill down will be around 20 feet and LPA has concerns of potential disruption due to noise that this project could cause to residents in care. LPA requested written plan to be submitted to CCL prior to start the expected construction September 14, 2025 along with copy of building permit from the City of Santa Rosa. The written plan should address how the facility will ensure the health and safety of residents in care while the construction occurs, as well as materials and equipment handling inaccessible to residents in care. Staff will be required to continuously remind and check all residents to make sure that they are not going to the construction site and notify their responsible parties.

During tour of the facility, LPA inquired with staff regarding bed rails documentation been posted on the walls of resident's rooms. Upon inquire with staff (S1) who entered the room made an inappropriate comment to R1, by referring to them as "this one" and R1 stare at them. LPA raised the concern about staff needs to be respectful with resident's personal rights to back up administrator who addressed with S1 this incident.

At approximately 9:10am, LPA/staff measured water temperature in faucets used by residents 129.2 and 126.5, which is not within the allowable range of 105 to 120 degrees F. Back up administrator adjusted water heater. **Civil Penalty assessed in total amount of $250.00 for repeated violation within 12 months.

At approximately 9:15am LPA/staff observed a bag of ten carrots sitting on the kitchen counter it was spoiled and 18 cans of thick and easy were expired as of 1/31/25. Food was not been stored in a safe manner as indicated by regulation. Food was discarded by staff.

During LPA's visit, there were no activities to be conducted with residents in care. LPA had a conversation with back up administrator who stated that residents are not engaged in any of the activities been offered. LPA suggested to review current activity calendar and update it to offer more engaging activities (technical violation issued). Continued on LIC809C...
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Marisol Cuadra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2025
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: 08/14/2025
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Continued from LIC809C...

At approximately 9:20am, LPA/staff attempted to flush the toilet in the bathroom across from room number six and it was not working. Electric face plate located in the kitchen is broken and it needs to be replaced, During last annual visit conducted on 8/14/24, LPA cited fence in backyard needed to be repaired, handrails broken and base of handrails cracked. There was a frame of wood with nails exposed. Per back up Administrator it was agreed to be repaired, but it wasn't fully repaired. **Civil Penalty assessed in total amount of $250.00 for repeated violation within 12 months.

LPA initiated file review at 10:00 am. LPA reviewed four residents files and three staff files. One out of four residents (R2) needs medical assessment to be updated and it was requested to their physician on 7/15/25 and facility is waiting on their response (technical violation issued). Resident's needs service plans are updated. The facility has implemented a computerized system to update resident's care plans and is maintained in the facility computer for accessibility. LPA/back up administrator discussed Dementia regulation changes including focus on person-centered care and provided resources including LIC602A form for their review. All three out of three staff do have current First Aid/CPR certificates and 20 hours of additional required training. Administrator Certificate for Lily Alcones, 7003673740, expires on 3/9/2026. Medications and medication records were reviewed.

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 and 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. **Civil Penalties assessed in total amount of $250.00 each for repeated violation within 12 months.

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

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Marisol Cuadra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/14/2025 02:46 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 08/14/2025 at 01:43 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: 08/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's/staff observation, interview and records review, the licensee did not comply with the section cited above in there is a lock in the exit gate, which it is identified as an emergency exit, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/15/2025
Plan of Correction
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 Back up Administrator removed the lock from emergency exit. The facility will submit plan of correction in how the facility will ensure compliance with this regulation. Hold an in-service training regarding fire clearance - emergency exits with all staff. Submit proof of training by 8/15/25.
Request Denied
Type A
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) 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 LPA/staff attempted to flush the toilet in the bathroom across from room number six. Electric face plate located in the kitchen is broken and it needs to be replaced, During last annual visit conducted on 8/14/24, LPA cited fence in backyard needed to be repaired, handrails broken and base of handrails cracked. There was a frame of wood with nails exposed which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/15/2025
Plan of Correction
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During the visit, Back up Administrator called maintenance person who came and fixed toilet issue, replaced electric face plate, adjusted deck handrails. Facility to submit requested written plan prior to start the expected construction on September 14, 2025 along with copy of building permit from the City of Santa Rosa.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Marisol Cuadra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/14/2025 02:46 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 08/14/2025 at 01:43 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: 08/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type A
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 LPA's/staff observation, the licensee did not comply with the section cited above in that water temperature in sink accessible to residents in care measured at 129.2 and 126.5 degrees F in the bathrooms, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/15/2025
Plan of Correction
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Facility adjusted water heater temperature and agreed to submit LIC9098 self-certification, then a follow up of two weeks 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 correction due date.

Type A
Section Cited
CCR
87555(b)(28)
General Food Service Requirements
(b) The following food service requirements shall apply: (28) All food shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's/staff observation a bag of ten carrots sitting on the kitchen counter it was spoiled and 18 cans of thick and easy were expired as of 1/31/25 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/15/2025
Plan of Correction
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Licensee to ensure that all food is stored and maintained in an appropriate manner in order to have no contamination of the food items. Submit plan of correction in how the facility will ensure compliance with this regulation. Hold an in-service training regarding food storage with all staff. Submit proof of training by 8/15/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Marisol Cuadra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2025


LIC809 (FAS) - (06/04)
Page: 6 of 10
Document Has Been Signed on 08/14/2025 02:46 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 08/14/2025 at 01:45 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: 08/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.269(a)(1)

§1569.269 Enumerated rights; severability (a) Residents of RCFE shall have all of the following rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other people. This requirement has not been met as evidence by:
Deficient Practice Statement
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Based on

Based on LPA’s/staff observations, the facility staff assisted residents in care using inappropriate comments by referring to them as "this one", which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/22/2025
Plan of Correction
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The facility will conduct all staff training regarding personal rights. Training subject, date of training and signed attendance forms to be submitted to CCL by POC due date.
Type B
Section Cited
CCR
87156(b)(1)(F)

87156 (b)(1)(F) Licensing Fees. In addition to fee set forth in subdivision , the department shall charge the following.. licensee fails to pay the annual licensing fee on or before the due date as indicated by postmark on the payment. This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in not paying the annual fee in the amount of $495, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/22/2025
Plan of Correction
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The licensee shall pay the annual fee and then submit in writing a plan how they shall ensure moving forward the annual fees are paid by the annual 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.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Marisol Cuadra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2025


LIC809 (FAS) - (06/04)
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