170107747-7-11-2023-21-AS-SHAN-CTMRKF-20230711130528

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 170107747
Report Date: 07/11/2023
Date Signed: 07/11/2023 01:05:37 PM

Document Has Been Signed on 07/11/2023 01:05 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:	07/11/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Arlene Wing, Licensee		TIME COMPLETED:	01:15 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 the facility and was greeted by staff Sarah Steptoe who contacted licensee, Arlene Wing. There is a total of 5 residents none are diagnosed with dementia. There are no residents currently on Hospice. At 9:10 AM LPA toured facility; 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 7/11/2023 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 116.7 degrees F. at time of visit falling within Title 22 Regulation range of 105 degrees F. and 120 degrees F. 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 & three staff records as well as two resident’s medications was conducted. LPA reviewed resident’s files at 10:45 AM and learned that 5 of 5 residents have an updated re-appraisals/needs & care plans and physician’s assessments (LIC 602A). Although during review Licensee informed resident (R1’s) records will need to be updated as R1 was sent out to the hospital twice in April and was admitted. Facility has not sent in required incident reports. Facility is being issued a citation for not following reporting requirements 87211(a) (see LIC 809D). 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: 07/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 3

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: 07/11/2023

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
26
27
28
29
30
31
32

LPA reviewed a sample of staff records at 11:45 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 expires on 8/22/2023.

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 7/11/2023 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 3/13/2023.

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 7/31/2023:

LIC 308 Designated
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Resident’s
Copy of Administrator Certificate
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: 07/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 07/11/2023 01:05 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: 07/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87211(a)

87211 (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the person the following: (1) A written report shall be submitted to the licensing agency & to responsible for the resident within 7 days of the occurrence This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on facility did not submit the required report within the 7 days for R1. R1 went to the hospital on 3 different occasions (4/27/2023 & 4/28/2023 ) and then admited to the hospital on 5/3/2023 where R1 was for a month and then moved to a post-acute. This is a potential risk to the H&S of residents in care.
	POC Due Date: 07/21/2023
	Plan of Correction
1 2 3 4	Facility to submit the required report for R1 by POC due date of 7/21/2023 . Facility to send in a written statement/plan on how they will ensure the required reports are sent in to CCL per regulation. by POC due date of 7/21/2023 to CCL.

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: 07/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3