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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 170107747
Report Date: 08/23/2022
Date Signed: 08/23/2022 10:55:37 AM


Document Has Been Signed on 08/23/2022 10:55 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:
(707) 275-2405
CITY:UPPER LAKESTATE: CAZIP CODE:
95485
CAPACITY:6CENSUS: 4DATE:
08/23/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Licensee, Arlene WingTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Hansen arrived unannounced to conduct a Case Management inspection and met with Licensee, Arlene Wing.

LPA is following up on a Technical Assistance given at annual inspection on 7/19/2022 for repairs to be completed on resident’s shower with broken tiles and what appeared to be dirty grout being discolored. During annual inspection licensee stated shower would be cleaned and tiles would be fixed at the end of 30 days.

During today’s follow up visit LPA observed work has been conducted on some bathroom tiles in shower and behind toilet. Dirty grout and tiles that were discolored appear to have also been worked on with over half of the shower being cleaned back to it’s original color. Licensee informed repairman injured knee last week, which has made the progress slow down. Licensee also stated residents are still using the bathroom. LPA advised licensee after repairman is finished working on bathroom each time, the debris needs to be cleaned up and paint cans and toxins need to be put away in a safe and secure location.

No deficiencies cited during today’s inspection

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2022
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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