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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 170107747
Report Date: 07/19/2022
Date Signed: 07/19/2022 11:22:33 AM


Document Has Been Signed on 07/19/2022 11:22 AM - 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:CLOVER VALLEY GUEST HOMEFACILITY NUMBER:
170107747
ADMINISTRATOR:WING, ARLENEFACILITY TYPE:
740
ADDRESS:820 CLOVER VALLEY ROADTELEPHONE:
7072752405
CITY:UPPER LAKESTATE: CAZIP CODE:
95485
CAPACITY:6CENSUS: 3DATE:
07/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Licensee/Administrator Arlene WingTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Hansen conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and was welcome by Licensee Arlene Wing. LPA arrived at facility and had temperature checked and logged. Facility has 3 residents.

At 9:10 AM LPA toured facility with Licensee; 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. 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 cabinet in the facility laundry room and locked hallway closet. There was a supply of cleaners, hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings. Fire Extinguisher was found to be last charged on 9/18/2021 at the time of the visit. Smoke Detector was found to be operational carbon monoxide detectors were unfunctional at time of visit, licensee fixed by end of visit. Medications are kept in a locked cabinet in the office. Residents bathroom faucet water tested 116 degrees F. at time of visit falling within Title 22 Regulation range of 105 degrees F. and 120 degrees F. A technical has been issued for facility to conduct repairs in residents shower and LPA will assess at case management in a month.

Infection Control:
Facility has submitted a mitigation program plan that has been approved and an Infection Control Plan. Posters have been placed at facility. 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 hall closet. All staff had masks on during this visit. All staff had PPE training required on file and have received N-95 fit testing. All staff have declined COVID vaccinations and have signed waivers on file.

Continue on LIC 809-C
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: CLOVER VALLEY GUEST HOME
FACILITY NUMBER: 170107747
VISIT DATE: 07/19/2022
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LPA reviewed Licensing Information System (LIS) with Administrator who stated that is correct and updated at this time, just to add Licensee’s cell # as mobile 707-349-2589. LPA advised facility to contact Local County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + or any virus in the facility.

LPA viewed Administrator Certificate for Arlene Wing # 6045408740 Exp. 8/22/2023.

LPA was presented with proof of CPR & 1st Aid certification for staff.

There were no deficiencies cited at this time.



LPA Hansen is requesting Licensee to update and submit the following documents by 7/29/2022 to SRRO:

LIC 308 Designated

LIC 500 Personnel Summary

LIC 610 Emergency Disaster Plan

LIC 9020 Register of Facility Resident’s

Proof of Liability Insurance

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2022
LIC809 (FAS) - (06/04)
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