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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 170107747
Report Date: 05/06/2025
Date Signed: 05/06/2025 10:46:36 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/01/2025 and conducted by Evaluator Julie Florio
COMPLAINT CONTROL NUMBER: 21-AS-20250501100125
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:
05/06/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Arlene Wing, LicenseeTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Uncleared adults on the facility grounds
INVESTIGATION FINDINGS:
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On 05/06/2025, Licensing Program Analysts (LPAs) Julie Florio and Christopher Arnhold arrived unannounced to initiate a 10-day complaint investigation and deliver complaint findings regarding LIC802 - Complaint Report #21-AS-20250501100125, which was received by Community Care Licensing (CCL) on 05/01/2025. LPAs met with Arlene Wing, Licensee. The complainant alleges that there are uncleared adults on the facility grounds.

During inspection, LPAs made observations, reviewed records, and conducted interviews. Based on observations made and interviews conducted, LPAs confirmed that there are three uncleared adults on the facility grounds (see LIC9099D and LIC421BG). A civil penalty in the amount of $1,100 if being issued during today's visit.

Continued on LIC9099C...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Julie FlorioTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 21-AS-20250501100125
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: CLOVER VALLEY GUEST HOME
FACILITY NUMBER: 170107747
VISIT DATE: 05/06/2025
NARRATIVE
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Continued from LIC9099...

Based on interviews conducted, observations made, and record review, the allegation listed above is SUBSTANTIATED. A finding that a complaint allegation is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiency is cited from Title 22 Regulations, Division 6.

Exit interview conducted. Copy of report discussed and provided to Licensee, whose signature on form confirms receipt of documents. Appeal rights provided.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Julie FlorioTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20250501100125
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 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: 05/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/16/2025
Section Cited
CCR
87355(e)
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87355 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:
This requirement is not met as evidenced by:
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Licensee to self certify that the three adults observed in the facility during today's inspection will get fingerprint cleared by 05/07/2025. Licensee to submit proof that this process has been intiated to CCL by POC due date 05/16/2025.
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Based on observations made and interviews conducted, LPAs confirmed that there are three uncleared adults on the facility grounds, which poses an immediate health, safety or personal rights risk to persons in care.
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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 MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Julie FlorioTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3