Creekwood

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced on 12/22/2022 to conduct a Required 1 Year inspection. LPA met with administrator Cynthia Viarata. This inspection was focused on the infection control procedures and practices of this facility. LPA was screened upon entry. COVID postings were present at the front entrance. LPA toured building and grounds with administrator which were clean and in good repair. Exits and walkways were free from obstructions. Facility had sufficient perishable and non-perishable food. Bathrooms are equipped with necessary grab bars and non-slip flooring. Medications were locked and secured in medication room. Toxins were secured and inaccessible. LPA observed carbon monoxide detectors throughout the facility. Fire extinguishers inspected were charged and current. Facility has sufficient personal protective equipment to support a resident in isolation. Staff have been given infection control training. Staff and residents have received COVID booster and flu shot. High touch surface areas are disinfected daily. LPA observed monthly activity schedule. Guitar and harp player were performing for residents during time of the inspection. LPA is requesting the following documents be submitted to Community Care Licensing within 30 days of today's inspection: LIC 308 Designation of Administrative Responsibility Evidence of Liability Insurance Exit interview conducted with Cynthia Viarata. Report was emailed to administrator. No deficiencies observed during today's inspection.the state’s words, verbatim · CDSS document, Dec 22, 2022

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Fernandes-Goes arrived to conduct a case management visit regarding two incident reports submitted to Community Care Licensing (CCL) for R1 & R2 which occurred on 6/16/2022. LPA met with Cynthia Virata - Administrator. On both occasions resident R1 & R2 AWOL/eloped while under facility responsibility. Resident R1 has a physician's report dated 2/3/2021 diagnostic of dementia and R2 dated 9/21/2020 diagnostic of MCI which states that residents are NOT able to leave facility unassisted at any time. Per facility staff resident R1 walked out of the facility and was found by staff on sidewalk on Tamalpais Ave while resident R2 was found by staff at wine festival. It seems that both residents left facility together. (see confidential name list, copies, LIC 809-D) Since this incident, facility has conducted staff training for elopement and facility elopement plan in which both have been submitted to the Department as prove of correction. (copy on file) Precautions have been taken by facility to avoid any other incident of elopement. 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. Appeal of Rights Given.the state’s words, verbatim · CDSS document, Aug 4, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(c) · Plan of correction due date: Aug 5, 2022

8746(f)(c) Basic Services. This requirement isn't meet as evidenced by: Based on incident reports Resident R1 & R2 eleoped from facility without staff knowledge on 6/18/22 the facility didn't comply on safetymeasures to address behaviors such as wandering for residents R1 & R2 which poses an immediate Health,Safety risk to residents in care.Per staff interviews,SIRs, & physician's reports, R1&2 left the facility w/out staff knowledge. (see copies)the state’s words, verbatim · CDSS document, Aug 4, 2022

Plan of correction: Facility agreed and conducted all staff training regarding elopment and have facility elopement plan reviewed and in place. Both have been submitted to CCLD on 7/12/2022. POC Cleared

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Fernandes-Goes conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and met with Administrator Cynthia Virata. There were 34 residents with 7 under hospice at facility. Facility has activities planned for residents during the day. LPA arrived at the facility and had her temperature checked and logged into a log. During facility tour on 2/4/2022 with administrator; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 1/2022 at the time of the visit. Sample test of Smoke Detectors & Carbon monoxide detector were found to be operational during this visit. Fire sprinklers are inspected annually, and inspection records are current with the last inspection being conducted on 12/9/2021. There was a sufficient supply of both perishable and nonperishable foods 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 has residents' with a special diet which is posted in the kitchen board w/ pictures. In addition, serving trays have residents' names with specific guidelines according with their needs. Toxins are stored in a locked linen, housekeeping area and outside storage. Dangerous items were stored inaccessible to clients. There was a supply of cleaners, hygiene products and paper products available for clients. All resident’s bedrooms have lighting & appropriate furnishings. Disaster drills are being conducted quarterly with records for last fire drill on 11/10/2021. Infection Control: Facility has submitted a mitigation program plan that has been approved. Some posters have been placed at entrance and bathrooms. Facility has hand sanitizer available; visitors and staff before coming into work have temperature checked. Continue 809-C Facility has PPE supply stored in office, beauty salon, med tech room, and basement. There has been new staff hired and new resident’s admission since COVID. Residents’ medications are stored and locked in the medication room. Facility has a 30-day supply of medication for clients. Residents are not wearing masks inside the facility, however; staff stated that they are able to wear masks when going on outings. All staff had masks on during this visit. In addition, facility has a designated area for visitors which are being allowed. Residents have also available virtual and telephone calls when contacting with family members and others. Staff have had all PPE training required on file and have acquired N-95 fit testing for staff. There were no deficiencies cited at this time. Department is requesting facility to submit the following update documents by 2/11/2022: LIC 308 Designated LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan LIC 610E-S Supplemental Emergency Disaster Plan for RCFE LIC 9020 Register of Facility Client’s/Resident’s Copy of Certificate of Liability Insurance Copy of Administrator Certificatethe state’s words, verbatim · CDSS document, Feb 4, 2022

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Fernandes-Goes arrived unannounced with the purpose of closing a complaint investigation. During subsequent complaint investigation LPA learned there are related deficiencies observed during the visit. LPA met with Cynthia Virata - Administrator. Following item were observed during investigation visits: LPA observed during interviews and resident's files review on 9/29/2021 & 11/22/2021 that facility has had a medication error on 9/27/2021. Resident R1 had a medication order discontinued by doctor on 9/20/2021 & 9/24/2021. Medication technician staff S1 dispensed discontinued order of 3 x 75 mg Clozapine and new order of 3 x 100 mg Clozapine dated 9/20/2021 instead only 3 x 100 mg of Clozapine until 9/26/2021. As per administrator, doctor and family member were contacted. Staff S1 received retraining on Relias on 10/6/2021. Per staff S1 interview, discontinued doctor's orders for 3 x 75 mg Clozpine wasn't submitted to the facility until 2 days later of new order. No deficiencies cited during this inspection.the state’s words, verbatim · CDSS document, Dec 22, 2021

Allegation investigated: Resident sustained injuries while in care.

The Department conducted a complaint investigation regarding the allegation listed above. Licensing Program Analyst Fernandes-Goes arrived unannounced for the purpose of closing the investigation and met with Paula Sauve - Licensee. On 9/29/2021, LPA Fernandes-Goes toured the facility; conducted interviews; acquired documentation; and made observations of the facility. During documentation review on file and observations with Cynthia Virata Administrator, and interviews of staff and resident R1, LPA learned that facility resident R1 was found with an injury; 911 was contacted; and resident was sent out to the ER. Per staff interview, “Resident R1 on 9/26/21 at 10:35 AM was observed by caregiver and called Med tech who enter the room to assist resident. Resident R1 had leg caught between rail and bed; staff noticed deep cut; 911 was contacted came back from hospital at 2:55 PM. Unsubstantiated It looked like she tried to move away and her leg got cut. Based on observation, interviews, and documentation review LPA wasn’t able to prove or disprove that facility staff neglected resident R1 while in care. R1 sustained injury although LPA obtained no evidence to support facility negligence and when injury was observed timely medical was provided. A finding that the complaint allegation of “Resident sustained injuries while in care.” is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies cited during this inspection.the state’s words, verbatim · CDSS document, Dec 14, 2021 · control 21-AS-20210927164908