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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803346
Report Date: 10/07/2025
Date Signed: 10/07/2025 03:29:26 PM

Document Has Been Signed on 10/07/2025 03:29 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:CREEKSIDE COTTAGEFACILITY NUMBER:
496803346
ADMINISTRATOR/
DIRECTOR:		STURGEON, KELLY J.FACILITY TYPE:
740
ADDRESS:621 ELY BLVD. S.TELEPHONE:
(707) 559-5062
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY: 6CENSUS: 6DATE:
10/07/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:20 AM
MET WITH:Kelly Sturgeon, Licensee/AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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License Program Analyst (LPA) Hansen arrived unannounced to conduct an annual inspection of facility. LPA met with Licensee/Administrator Kelly Sturgeon. This Residential Care Facility for the Elderly is single story with 5 bedrooms that has been approved by the Petaluma Fire Department for 6 Nonambulatory residents. Hospice waiver has been approved for 4 residents. There is a total of 6 residents, 5 with a diagnostic of dementia, and 2 are currently on Hospice.

LPA toured the facility on 10/7/2025 at 8:25 AM with licensee/administrator Kelly Surgeon facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Exits were equipped with auditory devices although auditory devices at front door and back door were not turned on (see LIC809D). Fire Extinguisher was found to be last charged on 3/15/2025 at the time of the visit. Combination smoke and carbon monoxide detectors were found to be operational during the visit. Hot water temperature measured within Title 22 acceptable regulation of 105 to 120 degrees F in 3 of 3 resident’s bathrooms while touring facility on 10/7/2025. The facility serves residents with dementia and has a plan of operation for special care and programming. There was a sufficient supply of both perishable and nonperishable food as required by Title 22 Regulations and grocery delivery to arrive today. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored under cabinet in the kitchen which was unlocked (see pics & LIC 809D). There was a supply of cleaners, hygiene products and paper products available for residents. The bathrooms designated for residents at the facility were supplied with paper towels and hand soap dispensers. Bathrooms were equipped with necessary grab bars, and slip-resistant mats, strips, or flooring in all bathtub and shower floors as required by Title 22 regulations. All bedrooms have lighting & appropriate furnishings.

At approximately 9:15AM LPA conducted a review of six resident & three staff records as well as resident’s medications. LPA reviewed resident’s files on 10/7/2025 and learned that 6 of 6 residents have an updated re-appraisals/needs & care plans and updated physician’s assessments (LIC 602A).


Continue on LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Shannan Hansen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/07/2025
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: CREEKSIDE COTTAGE
FACILITY NUMBER: 496803346
VISIT DATE: 10/07/2025
NARRATIVE
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Continue from LIC809:

Medications are centrally stored, although at approx. 8:30am LPA observed unlocked cabinet in the facility office area between kitchen and dining room (see pics & LIC809D). The Medications of 2 out of 2 residents were found to be given according to physicians’ directions on 10/7/2025 at 10:15 AM.

LPA reviewed a sample of staff records at 10:45AM on 10/7/2025 and learned that all facility staff present and a sample of other individuals who require caregiver background checks have received criminal record clearances or exemptions. Direct care staff annual training requirements for 2024/2025 are on file. LPA was presented with proof of CPR & 1st Aid certification for staff that files were reviewed although 1 staff only had CPR/AED (see LIC809D). LPA reviewed health records for staff and observed 1 staff (S1) not having proof of TB results on file (see LIC 9102 Advisory Notes) Administrator sending.

Kelly Sturgeon Administrator Certificate # 7007364740 expires on 1/5/2027.

Disaster Drills have been conducted quarterly, in different shifts with the last being on 9/22/2025.

Appeal of Rights Given.



The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.


LPA Hansen is requesting Licensee to update the following documents by 10/31/2025:

LIC 308 Designated
LIC 309 Administrative Organization
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan – if changes
LIC 9020 Register of Facility Resident’s
Copy of Administrator Certificate
Copy of Certificate of Liability Insurance
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Shannan Hansen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025
LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 10/07/2025 03:29 PM - It Cannot Be Edited


Created By: Shannan Hansen On 10/07/2025 at 12:09 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: CREEKSIDE COTTAGE
FACILITY NUMBER: 496803346

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(2)

87465(h)(2) Incidental Medical & Dental Care: (h) The following requirements shall apply...(2)Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation (see pics) during Annual inspection, the licensee did not comply with the section cited above in finding medication cabinet unlocked, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/17/2025
Plan of Correction
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 Licensee to submit documentation of staff training on regulation 87465(h)(2) with date, time, subject, duration, staff names and signatures of attendance by POC due date 10/17/25 to CCL to clear the citation.
Type B
Section Cited
CCR
87309(a)
87309 (a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation (see pics), the licensee did not comply with the section cited above in finding kitchen cabinet under sink unlocked, containing cleaning products, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/17/2025
Plan of Correction
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Cabinet door was locked immediately. Administrator plans to provide an in-service with staff to ensure disinfectants/cleaning solutions are always stored inaccessible to residents in care. Administrator to submit signed log in sheet of trainings with dates by POC due date of 10/17/2025 to clear citation.
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:
Shannan Hansen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/07/2025 03:29 PM - It Cannot Be Edited


Created By: Shannan Hansen On 10/07/2025 at 12:19 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: CREEKSIDE COTTAGE
FACILITY NUMBER: 496803346

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(b)(2)(d)

87705(b)Licensees shall be responsible for the following: (2)For facilities with fewer than 16 residents (d)The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors…accessible to those residents who may be at risk…

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation & interview with licensee they did not comply with the section cited above in finding front and back doors accessible to busy road not having auditory device turned on with residents having dementia diagnosis which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/17/2025
Plan of Correction
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 Licensee to submit documentation of staff training on regulation 87705(b)(2)(d) with date, time, subject, duration, staff names and signatures of attendance by POC due date 10/17/25 to CCL to clear the citation.
Type B
Section Cited
CCR
87411(c)(1)

(c)All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1)Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's record review and interview with Licensee, they did not comply with the section cited above in finding staff (S1) did not have current First Aid certification which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/17/2025
Plan of Correction
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Licensee/Administrator to ensure all staff have required first aid certification training. Submit proof of staff's first aid certification by POC due date of 10/17/2025
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:
Shannan Hansen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2025


LIC809 (FAS) - (06/04)
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