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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803282
Report Date: 08/28/2025
Date Signed: 08/28/2025 12:54:56 PM

Document Has Been Signed on 08/28/2025 12:54 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: 5DATE:
08/28/2025
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:25 AM
MET WITH:Lily Alcones (Administrator)TIME VISIT/
INSPECTION COMPLETED:
01:09 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cuadra conducted an unannounced case management inspection of this licensed senior care facility and met with Administrator Lily Alcones. The purpose of this case management inspection is to follow up on uncleared deficiencies cited during annual visit conducted on 8/14/2025. As of today's inspection citations 87303 (a) with POC date extended to 8/20/25, 87303 (e)(3) with POC date extended to 8/20/25, 1569.269(a)(1) with POC date 8/22/25 and 87156(b)(1)(F) with POC date 8/22/25 are outstanding. On 8/15/25, Back up Administrator submitted an extension request of POC due date, which it was granted by LPA. On 8/20/25, back up administrator submitted an unlawful appeal request, where it was requested by LPM Bertozzi to clarify by providing supporting documentation for their appeal as well as submitting requested written plans and an explanation of why the citation should not have been issued to continue the appeal process. However, as of today CCL have not received any of the documentation requested to clear the outstanding deficiencies.

During today's visit, Administrator provided proof of correction for citations 87303 (e)(3). Deficiency cleared from annual inspection 8/14/2025. Administrator could not provide proof of to clear citation:

-87303(a) - Facility to submit requested written plan prior to start the expected construction on September 14, 2025, 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. Continue on LIC809C...

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Marisol Cuadra
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2025
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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Document Has Been Signed on 08/28/2025 12:54 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 08/28/2025 at 12:21 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: 08/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/05/2025
Section Cited
HSC
1569.269(a)(1)

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§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:
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Administrator could not provide proof of training to clear citation. 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.
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Based on LPA’s/staff observations during abbual visit conducted on 8/14/25, 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.
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Type B
09/05/2025
Section Cited
CCR87303(a)

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(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:
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Facility to submit requested written plan prior to start the expected construction on 9/14/25, addressing how the facility will ensure the health & safety of residents in care while the construction occurs, as well as materials, equipment handling, and notifying their responsible parties.
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Based on LPA/staff during abbual visit conducted on 8/14/25, facility failed to submit requested written plan regarding construction project about how the facility will ensure the residents’ safety and personal rights, which poses a potential ealth, safety or personal rights risk to persons in care.
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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: 08/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/28/2025 12:54 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 08/28/2025 at 12:29 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: 08/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
09/05/2025
Section Cited
CCR
87156(b)(1)(F)

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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:
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The licensee paid the annual fee, but did not submit in writing a plan how they shall ensure moving forward the annual fees are paid by the annual due date.
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Based on record review, during abbual visit conducted on 8/14/25, the licensee did not comply with the section cited above in paying the annual fee in the amount of $495, but did not submitted written plan, which poses a potential health, safety or personal rights risk to persons in care.
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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: 08/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
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: 08/28/2025
NARRATIVE
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Continued from LIC809...

- 1569.269(a)(1) - 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.

- 87156(b)(1)(F) - The licensee paid the annual fees, but they did not submit in writing a plan how they shall ensure moving forward the annual fees are paid by the annual due date.

During last annual visit, LPA requested back up Administrator, Arthur Alcones to submit 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 away for a long period of time from the facility to ensure resident's care needs will be met in case of an emergency and Community Care Licensing inspections. Today, Administrator agreed to submit requested written plan regarding timely response to come to the facility to ensure resident's care needs will be met in case of an emergency and Community Care Licensing inspections.



LPA issued citation with new POC dates. Exit interview conducted with Administrator.

Deficiencies are cited from the California Code of Regulations (CCRs), Title 22, Division 6, Chapter 8 and the Health and Safety Code. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Appeal Rights Given.

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

DATE: 08/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2025
LIC809 (FAS) - (06/04)
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