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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 170107747
Report Date: 12/21/2021
Date Signed: 12/21/2021 01:10:09 PM

Document Has Been Signed on 12/21/2021 01:10 PM - 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
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:
12/21/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Arlene Wing - AdministratorTIME COMPLETED:
01:10 PM
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On 12/21/2021 at approximately 12:30 PM Licensing Program Analyst (LPA) Hansen arrived unannounced to conduct a Case Management inspection and met with Administrator, Arlene Wing. LPA was temperature check and singed in on provided log for all visitors.

LPA was following up on a previous complaint regarding infection control/Mitigation Plan and that facility is following through on their plan of correction: All staff will wear required face mask – Vaccine exemptions and documentation of weekly COVID testing are kept in file and that check in log has temperatures included and are documented both in and out each day of work. LPA confirms staff log in and out sheets have been filled in with temperatures and signed Religious exemptions for all staff as well as copies of weekly testing were provided.

LPA dropped off additional postings for facility.

No deficiencies cited during this inspection.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 12/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/21/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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