170107747-8-27-2024-21-AS-SHAN-D8JQQD-20240827122209

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 170107747
Report Date: 08/27/2024
Date Signed: 08/27/2024 03:23:14 PM

Document Has Been Signed on 08/27/2024 03:23 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	CLOVER VALLEY GUEST HOME		FACILITY NUMBER:	170107747
ADMINISTRATOR:	WING, ARLENE		FACILITY TYPE:	740
ADDRESS:	820 CLOVER VALLEY ROAD		TELEPHONE:	(707) 275-2405
CITY:	UPPER LAKE	STATE: CA	ZIP CODE:	95485
CAPACITY:	6	CENSUS: 5	DATE:	08/27/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Arlene Wing, Licensee/Administrator		TIME COMPLETED:	12:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	License Program Analyst (LPA) Hansen arrived unannounced to conduct an annual required – 1 yr. inspection of this RCFE and was greeted by staff Sarah Steptoe. LPA met with licensee/Administrator, Arlene Wing. There is a total of 5 residents none are diagnosed with dementia. There are no residents currently on Hospice. At 9:00 AM LPA toured facility with staff & 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 2/1/2024 at the time of the visit. Smoke Detectors and carbon monoxide detectors were found to be operational at the time of visit. Residents bathroom faucet water tested 119 & 131.7 degrees F. at time of visit, falling out of Title 22 Regulation range of 105 degrees F. and 120 degrees F , Facility to put a sign up for individual bathroom that temp exceeds 125 (see LIC 9102). There was a supply of cleaners, hygiene products and paper products available for residents. The bathrooms designated for residents at the facility were supplied with paper towels and hand soap dispensers. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom shower. A review of five resident & two staff records as well as two resident’s medications was conducted. LPA reviewed resident’s files at 9:45 AM and learned that 5 of 5 residents have an updated re-appraisals/needs & care plans and physician’s assessments (LIC 602A). Continue on LIC 809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024

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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Document Has Been Signed on 08/27/2024 03:23 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87405(a)

87405 Administrator - Qualifications and Duties 87405 (a) All facilities shall have a qualified and currently certified administrator. This requirement is not met as evidenced by: Based on LPA and Admin observation and record review, the licensee did not comply with the
	Deficient Practice Statement
1 2 3 4	Based on LPA and Admin observation and record review, the licensee did not comply with the section cited above in that Arlene Wing, Administrator could not provide a copy of current Administrator Certificate or provide copy of email indicating receipt of renewal payment from CCL, Admin indicated to LPA they completed most of the hours of training but not all which poses a immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/30/2024
	Plan of Correction
1 2 3 4	Admin to submit picture of email and/or letter indicating receipt of renewal payment for Administrator Certificate from CCL or picture of current Administrator Certificate by plan of correction due date 8/30/2024.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024

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: 08/27/2024

NARRATIVE

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LPA reviewed a sample of staff records at 10:45 AM and learned that all facility staff present and a sample of other individuals who require caregiver background checks have received criminal record clearances or exemptions. Direct care staff annual training requirements are current. LPA was presented with proof CPR & 1^st Aid certification for staff of files reviewed are current. Arlene Wing Administrator Certificate # 6045408740 expired on 8/22/2023. Administrator informed they have completed most of the required training hours and will submit. LPA is citing facility for no current Administrator Certificate 87405(a) (see LIC809-D).

Medications were centrally stored in locked cabinet in facility office area. The Medications of 2 out of 5 residents were found to be given according to physicians’ directions on 8/27/2024 at 11:55 AM. Centrally Stored Medication Record (CSMR) of 2 out of 5 residents were found to be complete and accurate.

Disaster Drills are conducted quarterly with the last one being conducted on 7/25/2024.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided..

LPA Hansen is requesting Licensee to update the following documents and submit to CCL by 9/17/2024:

LIC 308 Designated (if changes)
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan (if changes)
LIC 9020 Register of Facility Resident’s
Copy of Administrator Certificate (when receive)
Copy of Certificate of Liability Insurance

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024

LIC809 (FAS) - (06/04)

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