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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 170107747
Report Date: 11/28/2021
Date Signed: 12/01/2021 09:36:03 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/19/2021 and conducted by Evaluator Shannan Hansen
COMPLAINT CONTROL NUMBER: 21-AS-20211119095959
FACILITY NAME:CLOVER VALLEY GUEST HOMEFACILITY NUMBER:
170107747
ADMINISTRATOR:WING, ARLENEFACILITY TYPE:
740
ADDRESS:820 CLOVER VALLEY ROADTELEPHONE:
(707) 275-2405
CITY:UPPER LAKESTATE: CAZIP CODE:
95485
CAPACITY:6CENSUS: 4DATE:
11/28/2021
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Licensee Arlene WingTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Facility is not following COVID-19 guidance
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Hansen arrived on 11/29/2021 at 11:30 am unannounced with the purpose of opening & closing a complaint investigation regarding the allegation listed above. LPA was greeted by Arlene Wing, Licensee who was not wearing a mask.

During this investigation LPA Hansen conducted interviews, made observations, and reviewed records. Following items were observed during investigation visits: LPA Hansen observed licensee not wearing required face mask in the facility, therefore not following COVID mandated guidance. LPA conducted a technical assistance virtual visit with the departments nurse consultant on 11/23/2021 and observed the facility not having required COVID postings, sign in log and licensee confirmed screening of staff and visitors was not occuring. LPA arrived and observed no sign in sheet and when requested from licensee ,provided one but there was no colomn date for temperatures. LIcensee informed LPA there are staff working at the facility that are not vacinated, licensee could not provide vaccinations exemptions or proof of weekly survelence testing of unvacinated staff.
Continue on LIC9099-C

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 21-AS-20211119095959
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: CLOVER VALLEY GUEST HOME
FACILITY NUMBER: 170107747
VISIT DATE: 11/28/2021
NARRATIVE
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Continued from LIC 9099 ....
Based on LPA's record review, facility is not following their mitigation plan submitted to the department. Facility had knowledge of first COVID positive result on 11/8/2021 but did not report to Community Care Licensing (CCL) until 11/12/2021. LPA identified facility is not following mitigation plan based on interview with Licensee. Designated staff (Licensee Arlene Wing) failed to report COVID case to CCL . Facility is not following staff and visitation screening prior to entering the facility. Facility did not have required postings identified in mitigation plan and they are not conducting survelance per mitigation plan, and they are not wearing PPE as identified in mitigation plan.

LPA provided licensee provider informational notices after technical assistance visit on 11/23/2021


The preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099D. Appeal Rights Given.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 21-AS-20211119095959
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: CLOVER VALLEY GUEST HOME
FACILITY NUMBER: 170107747
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/30/2021
Section Cited
CCR
87468.1(a)(2)
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87468.1(a)Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.This requirement has not been met as evidence by:
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Licensee to submit a plan to ensure in-compliance with reporting requirements and following mitigation plan submitted to CCL on 6/7/2021.
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Based on interviews with staff, observation, and record review Licensee did not follow mandated guidance of mitigation plan and not wearing required face mask & not provide vaccinations exemptions or proof of weekly survelence testing of unvacinated staff.
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Type B
12/09/2021
Section Cited
CCR
87211(a)(2)
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87211 (a)Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (2)Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate.This requirement has not been met as evidence by:
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Licensee to submit a plan to ensure in-compliance with reporting requirements and following mitigation plan submitted to CCL on 6/7/2021.
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Based on interviews with staff, observation, and record review Licensee did not inform CCL of COVID positive case as required by signed mitigation plan until 4 days after confirmation of results. Not within the 24 hour timeframe for a pandemic.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2021
LIC9099 (FAS) - (06/04)
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