<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803441
Report Date: 07/29/2025
Date Signed: 07/30/2025 08:40:58 AM

Document Has Been Signed on 07/30/2025 08:40 AM - 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 PLACEFACILITY NUMBER:
496803441
ADMINISTRATOR/
DIRECTOR:		STURGEON, KELLYFACILITY TYPE:
740
ADDRESS:617 ELY BOULEVARD SOUTHTELEPHONE:
(707) 559-3173
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY: 6CENSUS: 6DATE:
07/29/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:15 AM
MET WITH:Danielle Nunez, DesigneeTIME VISIT/
INSPECTION COMPLETED:
11:50 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
License Program Analyst (LPA) Hansen arrived unannounced at 8:15AM to conduct an annual inspection of the facility. LPA met with staff/designee Danielle Nunez as Licensee/Administrator Kelly Sturgeon was not available. Facility is single story with 5 bedrooms that has a fire clearance by the Petaluma Fire Department granting 6 Non-Ambulatory of which 1 may be bedridden (rm 4). Hospice waiver granted for 4 residents. There is a total of 6 residents, 3 with a diagnostic of dementia. There is 1 resident currently on Hospice.

LPA toured the facility on 7/29/2025 at 8:30 AM with designee; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Exits were equipped with auditory devices. Fire Extinguisher was found to be last charged on 3/22/2025 at the time of the visit. Smoke detectors & combination carbon monoxide were found to be operational during the visit. Hot water temperature measured between 110.3 degrees F and 112.1 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 2 of 2 resident’s bathrooms while touring facility on 7/29/2025. The facility serves residents with dementia and has a plan of operation for special care and programming. There was a sufficient supply of nonperishable and 7-day supply of perishable as required by Title 22 regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Facility oven and stove have protective mechanisms of buttons that must be held for over 5 seconds before heating element will turn on to prevent burns or fire, as per Title 22 regulations. Toxins are stored in a locked cabinet in the kitchen and under locked bathroom sink cabinets. Sharps are kept in locked kitchen drawer.

There was a supply of cleaners, hygiene products and paper products available for residents. The bathrooms designated for residents at the facility were supplied hand soap dispensers. Bathrooms contained necessary grab bars and slip-resistant mats, strips, or flooring in all bathtub and or shower floors as required by Title 22 Regulations. All bedrooms have lighting & appropriate furnishings. Continue on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Shannan Hansen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/29/2025
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 5
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)
Page: 2 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: CREEKSIDE PLACE
FACILITY NUMBER: 496803441
VISIT DATE: 07/29/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued from LIC809

A review of six resident & four staff records as well as two resident’s medications was conducted. LPA reviewed resident’s files at 9:00 AM and learned that 6 of 6 residents have an updated re-appraisals/needs & care plans and physician’s assessments (LIC 602A) were complete.

LPA reviewed a sample of staff records at approximately 10:00 AM 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. Kelly Sturgeon Administrator Certificate # 7007364740 expires on 1/5/2027.



Medications were centrally stored in locked cabinet in the facility office area between kitchen and dining room. The Medications of 2 out of 2 residents were found to be given according to physicians’ directions on 7/29/2025 at 8:45 AM. Centrally Stored Medication Record (CSMR) of 2 out of 2 residents were found to be complete and accurate. Activities of; live ukulele player 2 times a week & accordion player 2 times a month, along with an art teacher instructs 2 times a month as well as exercise classes for range of motion with instructor 2 times a week. Facility recently went to Armstrong woods for the day jointly with some families.

Disaster Drills are conducted quarterly with the last one being conducted on 7/12/2025.

There were no deficiencies cited at this time.

LPA Hansen is requesting Licensee to update the following documents and submit to CCL by 8/15/2025:



LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan (if changed)
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: 07/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2025
LIC809 (FAS) - (06/04)
Page: 5 of 5