SPRING CREEK LODGE

Official classification

Type B

Official code

87405(d)(2)

Regulation authority

CCR

What the official deficiency says

Administrator - Qualifications and Duties 87405(d)(2) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. (2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This regulation was not met as evidenced by Licensee/Administrators not engaging in the CHOW process as directed in the 9/15/2025 Office meeting

Deadline recorded: Jul 29, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87109(b)

Regulation authority

CCR

What the official deficiency says

87109 Transferability of License (b)The licensee shall notify the licensing agency and all residents receiving services, or their representatives, in writing as soon as possible and in all cases at least thirty (30) days prior to the transfer of the property or business... This requirement is not met as evidenced by:Based on interview & record review, the licensee did not comply with the section cited above in the licensee did not notify Community Care Licensing within thirty (30) business days of the transfer of the facility to a Limited Liability Corporation which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee to notify CCL regarding their choice to either remove facilities from LLC or keep them in the LLC by no later than plan of correction due date 9/29/25. If they choose to keep in the LLC, licensee will provide proof to Community Care Licensing that an application has been submitted to the Centrailized Application Bureau by plan of correction due date of 10/13/2025

Deadline recorded: Sep 29, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.269(a)(1)

Regulation authority

HSC

What the official deficiency says

§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: 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.

Official plan of correction

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.

Deadline recorded: Sep 5, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

(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: 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.

Official plan of correction

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.

Deadline recorded: Sep 5, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87156(b)(1)(F)

Regulation authority

CCR

What the official deficiency says

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: 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.

Official plan of correction

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.

Deadline recorded: Sep 5, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87202(a)

Regulation authority

CCR

What the official deficiency says

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's/staff observation, interview and records review, the licensee did not comply with the section cited above in there is a lock in the exit gate, which it is identified as an emergency exit, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/15/2025 Plan of Correction Back up Administrator removed the lock from emergency exit. The facility will submit plan of correction in how the facility will ensure compliance with this regulation. Hold an in-service training regarding fire clearance - emergency exits with all staff. Submit proof of training by 8/15/25.

Official classification

Type A

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

(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: Deficient Practice Statement Based on LPA/staff attempted to flush the toilet in the bathroom across from room number six. Electric face plate located in the kitchen is broken and it needs to be replaced, During last annual visit conducted on 8/14/24, LPA cited fence in backyard needed to be repaired, handrails broken and base of handrails cracked. There was a frame of wood with nails exposed which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/15/2025 Plan of Correction During the visit, Back up Administrator called maintenance person who came and fixed toilet issue, replaced electric face plate, adjusted deck handrails. Facility to submit requested written plan prior to start the expected construction on September 14, 2025 along with copy of building permit from the City of Santa Rosa.

Official classification

Type A

Official code

87303(e)(3)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's/staff observation, the licensee did not comply with the section cited above in that water temperature in sink accessible to residents in care measured at 129.2 and 126.5 degrees F in the bathrooms, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/15/2025 Plan of Correction Facility adjusted water heater temperature and agreed to submit LIC9098 self-certification, then a follow up of two weeks water log of water temperature readings with readings of water within regulation. Water log to be submitted with pictures of temperature with therometer reading present in picture. Water log and pictures to be submitted to CCL by plan of correction due date.

Official classification

Type A

Official code

87555(b)(28)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (28) All food shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's/staff observation a bag of ten carrots sitting on the kitchen counter it was spoiled and 18 cans of thick and easy were expired as of 1/31/25 which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/15/2025 Plan of Correction Licensee to ensure that all food is stored and maintained in an appropriate manner in order to have no contamination of the food items. Submit plan of correction in how the facility will ensure compliance with this regulation. Hold an in-service training regarding food storage with all staff. Submit proof of training by 8/15/25.

Official classification

Type B

Official code

1569.269(a)(1)

Regulation authority

HSC

What the official deficiency says

§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: Deficient Practice Statement Based on Based on LPA’s/staff observations, 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.

Official plan of correction

POC Due Date: 08/22/2025 Plan of Correction 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.

Official classification

Type B

Official code

87156(b)(1)(F)

Regulation authority

CCR

What the official deficiency says

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: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in not paying the annual fee in the amount of $495, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/22/2025 Plan of Correction The licensee shall pay the annual fee and then submit in writing a plan how they shall ensure moving forward the annual fees are paid by the annual due date.

Official classification

Type A

Official code

87355(e)

Regulation authority

CCR

What the official deficiency says

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: This requirement is not met as evidenced by: Deficient Practice Statement Based on LPAs and Admin observation, interview, and record review, the licensee did not comply with the section cited above in that staff (S1) did not have fingerprint clearance and not associated to the facilitywhich poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/16/2024 Plan of Correction Facility to submit LIC9098 self-certifying that S1 will not be present in any capacity at facility until S1 has fingerprint clearance and is associated to the facility.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

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: Deficient Practice Statement Based on LPAs and Admin observation, the licensee did not comply with the section cited above in that LPAs observed window in back bathroom in hallway to be broken, does not stay up when lifted, will not stay open. LPAs observed hole in wall on left side of the refrigerator. Backyard deck in disrepair, handrails broken and base of handrails cracked. Fence in backyard also in disrepair. Planks separated from fence with nails exposed. Large fence surrounding the perimeter of the facility is also in disrepair, boards separating from fence and nails exposed. Vents on side of house have gaps and black film substance. Per LPAs conversation with Admin they agree to repair, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/05/2024 Plan of Correction Facility to submit pictures of repaired fences, deck handrails, side yard gate, bathroom window, vent gaps on side of house repaired with black substance removed, and hole in wall in kitchen repaired by plan of correction due date.

Official classification

Type B

Official code

87303(e)(3)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPAs observation, the licensee did not comply with the section cited above in that water temperature in sink accessible to residents in care measured at 158 degrees F in the kitchen, LPA could not get a hot water reading in the bathroom across from room six, the water never got hot after running the water for four minutes which is not within the allowable range of 105 to 120 degrees F, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/29/2024 Plan of Correction Facility to submit two week water log of water temperature readings with readings of water within regulation. Water log to be submitted with pictures of temperature with therometer reading present in picture. Water log and pictures to be submitted to CCL by plan of ocrrection due date.

Official classification

Type B

Official code

1569.72(f)

Regulation authority

HSC

What the official deficiency says

(f) Notwithstanding the length of stay of a bedridden resident, every facility admitting or retaining a bedridden resident, as defined in this section, shall, within 48 hours of the resident’s admission or retention in the facility, notify the local fire authority with jurisdiction in the bedridden resident’s location of the estimated length of time the resident will retain his or her bedridden status in the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPAs and Admin record review, the licensee did not comply with the section cited above in that R1 is indicated as bedridden on their physician's report. However, facility does not have fire clearance for beridden residents. Admin unable to produce proof of notification to the Santa Rosa Fire Dept, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/29/2024 Plan of Correction Facility to submit either updated physician's report clarifying ambulatory status of resident R1 as not bedridden or facility to provide proof of fax notification to Santa Rosa Fire Dept notifying them of the bedridden status of R1 by plan of correction due date.

Official classification

Type A

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

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: Deficient Practice Statement Based on LPA and administrator observation and interviews with administrator back deck has wood scrap piles with nails protruding due to remodeling, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/29/2023 Plan of Correction Administrator agrees to remove piles of wood scraps today 9/28/2023. Administrator will submit a picture of cleared piles to notify CCL, by POC due date.

Official classification

Type B

Official code

87458(a)

Regulation authority

CCR

What the official deficiency says

(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA record review and interview with administrator, the licensee did not comply with the section cited above in one out of six residents physician's report (R2) was not updated as stated per regulations, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/19/2023 Plan of Correction Administrator agreed to send self certification to CCL that LIC602s have been updated by POC due date. LPA will conduct case management ro review.

Official classification

Type B

Official code

87463(c)

Regulation authority

CCR

What the official deficiency says

(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA observation and record review the licensee did not comply with the section cited above in five out of six residents' (R1, R2, R3, R4 & R5) care plans were not updated within the last 12 months, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/19/2023 Plan of Correction Administrator agreed to send self certification to CCL that care plans have been updated by POC due date. LPA will conduct case management ro review.