Creekside Cottage

Type of visit: Case Management - Annual Continuation

License Program Analyst (LPA) Shannan Hansen arrived at 8:15 AM to complete an unannounced annual inspection and was welcomed by staff Alondra Amezcua who contacted Licensee/Administrator Kelly Sturgeon who arrived shortly after. There is a total of 6 residents, all with a diagnostic of dementia, with 3 on hospice. LPA continued inspection with a review of six resident & five staff records as well as two resident’s medications conducted. LPA reviewed resident’s files at 8:40 AM on 10/13/2023 and learned that 6 of 6 residents have an updated re-appraisals/needs & care plans and updated physician’s assessments (LIC 602A). Medications were centrally stored in locked cabinet in the facility office area between kitchen and dining room at 10:00 AM on 10/13/2023. The Medications of 2 out of 2 residents were found to be given according to physicians’ directions on 10/13/2023 at 10:15 AM. Centrally Stored Medication Record (CSMR) of 2 out of 2 residents were found to be complete and accurate. LPA reviewed a sample of staff records at 9:30 AM on 10/13/2023 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 2022/2023 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 although is signed up for First Aid today (see LIC 9102 Advisory Notes). LPA reviewed health records for staff and observed 1 staff (S1) not having proof of TB in file (see LIC 9102 Advisory Notes) Administrator sending. Kelly Sturgeon Administrator Certificate # 6023921740 expires on 1/5/2025. Continue LIC 809-C No deficiencies cited during today's inspection. LPA Hansen is requesting Licensee to update the following documents by 10/31/2023: LIC 308 Designated LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan – if changes LIC 9020 Register of Facility Client’s/Resident’s Copy of Administrator Certificate Copy of Certificate of Liability Insurancethe state’s words, verbatim · CDSS document, Oct 13, 2023

The state marks this report as 6 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

License Program Analyst (LPA) Hansen arrived unannounced to conduct an annual required – 1 yr. visit of the facility. LPA was welcomed by Licensee/Administrator Kelly Sturgeon. There is a total of 6 residents and all 6 with a diagnostic of dementia. There is three residents currently on Hospice. LPA toured the facility on 10/10/2023 at 12:50 PM 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 and all auditory devices were working properly. Fire Extinguisher was found to be last charged on 3/15/2023 at the time of the visit. Smoke detectors 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 10/10/2023. 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. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored in a locked cabinet in the kitchen. 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 non-slip floors/mats were present in the bathroom shower. All bedrooms have lighting & appropriate furnishings. Resident’s beds were outfitted with mattress pads as required by Title 22 Regulations # 87307 on 10/10/2023 at 1:30 PM. LPA reviewed Licensing Information System (LIS) with licensee/administrator who stated that is corrected and updated at this time; no need to change any of the information. In addition, LPA advised facility to check with the County regarding what is the County Emergency Plan; ensure that disaster drills are conducted in different shifts, and review facility emergency plan to ensure accuracy according to the needs of facility residents. Disaster Drills have been conducted quarterly with the last one being conducted on 9/24/2023. Continue on LIC 809-C. LPA initiated a file review of six resident files & five personnel files but were unable to complete. LPA was also unable to review medication and will return at a later date to complete annual inspection. No deficiencies cited during today's inspectionthe state’s words, verbatim · CDSS document, Oct 10, 2023

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Hansen arrived unannounced at facility for the purpose of conducting a Case Management- incident inspection regarding a medication error. LPA met with Administrator Kelly Sturgeon. LPA is following up regarding a self-reported Incident Report received by Community Care Licensing (CCL) on 01/06/2023 of a medication error. The error was identified on 01/02/2023 that included 8 previous errors in the past month due to pm shift staff accidentally over medicating resident on antidepressant medication. (See LIC809-D) Responsible party and prescribing physician were notified of the medication error. 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 providedthe state’s words, verbatim · CDSS document, Jan 12, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(5) · Plan of correction due date: Jan 13, 2023

87465(a)(5) Incidental Medical and Dental Care. A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: The licensee shall assist residents with self-administered medications as needed. Based off self-reported incident report and interview with Administrator, the PM care staff over medicated the resident on antidepressants. This is an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 12, 2023

Plan of correction: Plan of Correction already fulfilled with training with all staff that pass medication. LPA obtained copies. POC cleared.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Hansen conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and was welcome by staff Danielle Nunez. Licensee Kelly Sturgeon conducted the visit. Facility has 5 residents, all with dementia, without any on hospice care at the time of visit. During facility tour on 10/6/2022 with Licensee/Admin Kelly Sturgeon, 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 3/7/2022 at the time of the visit. Smoke Detectors & Carbon monoxide detector was found to be operational during the visit. 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. Toxins are stored in a locked closet by the laundry/resident’s bathroom. Dangerous items were stored inaccessible to residents. There was a supply of cleaners, hygiene products and paper products available for residents. Residents' bedrooms have lighting & appropriate furnishings. Water temperature in resident's bathrooms measured 113.5 degrees F and 114.6 degrees F which are within acceptable range of 105 to 120 degrees F. Residents’ medications are centrally stored and locked in the office area by dining room. Facility has a 30-day supply of medication for residents. All staff had masks on during this visit. Facility has activities for residents such as group working exercises, reading word game, and other activity plans for residents during the day. Disaster Drills have been conducted quarterly with the last one being conducted this morning, a fire drill was conducted for both NOC and PM shifts, 10/6/2022. Continue LIC 809-C Infection Control: Facility has submitted a mitigation program plan and infection control plan that has been approved. Posters have been placed at facility and entrance has hand sanitizer and other items designated for visitors and staff before coming into work. Facility has PPE supply stored in outside shed, office, and bathroom. In addition, facility has a designated area for visitors which are being allowed for scheduled visits. Residents also have available Zoom, Facetime, and telephone calls when contacting with family members and others. Staff had all PPE training required on file and have obtained N-95 fit testing. LPA Hansen reviewed Licensing Information System (LIS) with staff who stated that is corrected and updated at this time. LPA advised facility to contact Local County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility. LPA was presented with proof of current CPR & 1st Aid certification for staff. Administrator Certificate is for Kelly Sturgeon # 6023921740 Exp. 1/5/2023 All staff have received COVID booster vaccinations. No deficiencies cited during todays inspection LPA Hansen is requesting Administrator to update and submit the following documents by 10/27/2022: LIC 308 Designated Articles of Corporation 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 Administrator Certificate Copy of Certificate of Liability Insurancethe state’s words, verbatim · CDSS document, Oct 6, 2022

Type of visit: Case Management - Incident

On 12/30/2021 at approximately 2:05 PM Licensing Program Analyst (LPA) Hansen arrived unannounced to conduct a Case Management inspection and met with Staff Danielle as Administrator was out. Staff called Administrator Kelly Sturgeon who confirmed staff can sign for her. LPA was temperature checked and logged on folder for all visitors. CCL received incident report that occurred 12/28/21 of a Resident (R1) was admitted to the facility on 12/10/21 with a primary diagnosis of stroke with aphasia and right sided weakness along with dementia. R1 is on Hospice with continuum. R1 has recently had shortness of breath with primary care physician thinks it is very likely lung cancer. R1 had previously been on antipsychotic medications but wife requested doctor to decrease so they did. Incident of 12/28/21 at approximately 3am R1 was very restless and went wandering into other residents’ room. Staff assisted and found R1 to appear highly agitated and confused when R1 punched staff in the ribs and shoulder. Staff required medical attention for contusions to left ribs and left shoulder. LPA spoke on the phone with Administrator when LPA arrived at facility to find out last night (12/29/21) while R1 was again up in the middle of the night Administrator found R1 and R1 grabbed Admins arm and twisted it and pulled Admin to the ground. Administrator was able to safely get up and get help. Administrator explained R1 has become extremely strong and been constantly trying to elope. This morning (12/30/21) R1 grabbed staff’s hand and squeezed it as hard as R1 could. Staff’s arm is now swollen and bruised. Administrator immediately called hospice nurse who instructed to call 911. R1’s wife arrived along with police and decided to have wife take R1 to Santa Rosa Kaiser as hospice nurse followed. Hospice nurse called ahead to make sure R1 got admitted. R1 was admitted and will be assed and not returning to the facility as his needs are beyond their care ability. No deficiencies cited during this inspection.the state’s words, verbatim · CDSS document, Dec 30, 2021

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Hansen conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and was welcome by staff Danielle Nunez. Licensee Kelly Sturgeon conducted the visit. Facility has 5 residents with 1 resident under hospice care. Facility has activities for residents such as group working exercises, reading word game, and other activity plans for residents during the day. During today’s visit facility was having their monthly celebration for Birthdays with homemade cupcakes decorated by residents. LPA arrived at the facility and had their temperature checked and logged into visitor’s binder. During facility tour on 10/22/2021 with Licensee/Admin Kelly Sturgeon, 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 03/2021 at the time of the visit. Smoke Detectors & Carbon monoxide detector was found to be operational during the visit. 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. Toxins are stored in a locked closet by the laundry/resident’s bathroom. Dangerous items were stored inaccessible to residents. There was a supply of cleaners, hygiene products and paper products available for residents. Residents' bedrooms have lighting & appropriate furnishings. Water temperature in resident's bathrooms measured 114 degrees F and 115.5 degrees F which are within acceptable range of 105 to 120 degrees F. Residents’ medications are stored and locked in the office area by dining room. Facility has a 30-day supply of medication for clients. All staff had masks on during this visit. Continue LIC 809-C Infection Control: Facility has submitted a mitigation program plan that has been approved. Posters have been placed at facility and entrance has small table with hand sanitizer and other items designated for visitors and staff before coming into work. Facility has PPE supply stored in outside shed, office, and bathroom. LPA was presented with proof of CPR & 1st Aid certification for staff. In addition, facility has a designated area for visitors which are being allowed for scheduled visits. Residents have also available Zoom, Facetime, and telephone calls when contacting with family members and others. Staff had all PPE training required on file and have obtained N-95 fit testing. LPA Hansen reviewed Licensing Information System (LIS) with staff who stated that is corrected and updated at this time. LPA advised facility to contact Local County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Disaster Drills have been conducted quarterly with the last one being conducted on 10/11/2021. All required documents received from facility in the last few months There were no deficiencies cited at this time.the state’s words, verbatim · CDSS document, Oct 22, 2021

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Fernandes-Goes and Hansen conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and was welcome by staff Josefina. Licensee was contacted and arrived during the visit. Facility has 5 residents with 1 resident under hospice care. Facility has activities for residents such as group working exercises, reading word game, and other activity plans for residents during the day. LPAs arrived at the facility and had their temperatures checked and logged into visitor’s binder. During facility tour on 7/22/2021 with staff Josefina first and then with Licensee/Admin Kelly Sturgeon, 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 03/2021 at the time of the visit. Smoke Detectors & Carbon monoxide detector was found to be operational during the visit. 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. Toxins are stored in a locked closet by the laundry/resident’s bathroom. Dangerous items were stored inaccessible to residents. There was a supply of cleaners, hygiene products and paper products available for clients. Residents' bedrooms have lighting & appropriate furnishings, and mattress pads are available for clients at the facility. Hot water temperatures measured degrees F within Title 22 acceptable regulations of 105 to 120 degrees F. Infection Control: Facility has submitted a mitigation program plan that has been approved. Posters have been placed at facility and entrance has small table with hand sanitizer and other items designated for visitors and staff before coming into work. Facility has PPE supply stored in outside shed, office, and bathroom. Facility has hired or admitted anyone new since COVID-19. Continue LIC 809-C Residents’ medications are stored and locked in the office area by dining room. Facility has a 30-day supply of medication for clients. Residents aren’t wearing masks inside the facility, however; licensee/admin 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 for scheduled visits. Residents have also available Zoom, Facetime, and telephone calls when contacting with family members and others. Staff had all PPE training required on file and have obtained N-95 fit testing. LPAs advised facility to contact Local County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Disaster Drills have been conducted quarterly with the last one being conducted on 5/21/2021. There were no deficiencies cited at this time.the state’s words, verbatim · CDSS document, Jul 22, 2021

The state marks this report as 4 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.