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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002729
Report Date: 08/19/2022
Date Signed: 08/19/2022 07:06:24 PM

Document Has Been Signed on 08/19/2022 07:06 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:CLOVERFACILITY NUMBER:
455002729
ADMINISTRATOR:SCHWARTZ, HEATHERFACILITY TYPE:
735
ADDRESS:19625 CLOVER ROADTELEPHONE:
(530) 782-2572
CITY:REDDINGSTATE: CAZIP CODE:
96002
CAPACITY: 4CENSUS: 4DATE:
08/19/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
06:00 PM
MET WITH:Heather Schwartz Admin & Jamie Murray COMTIME COMPLETED:
07:30 PM
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08/19/2022 Licensing Program Analysts (LPA) Shannon Diegoruelas, arrived at the facility unannounced to conduct a Health & Safety Inspection a water well that has went dry. LPA met with Heather Schwartz Admin and Jamie Murray Chief Operations Manager and explained the purpose of the visit. Prior to initiating the Heath and Safety Inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA contacted facility and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical mask. Additionally, LPA was screened by Administrator.

LPA and the staff toured facility to ensure health and safety of residents in care. Areas toured include but are not limited to: laundry room with Mount Shasta Spring water that is being delivered in in 5 gallon containers, two (2) bathrooms with flushing water for toilets, kitchen with 1 gallon spring water bottles and potable water for hand washing, garage with 1600 gallon water tank and proper plumbing to facility, and an out door area with a porta potty. Met with 1 resident who said he was overall good. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA found facility to be in substantial compliance at this time.

No deficiencies are being cited as a result of today’s inspection.

Exit interview conducted and copy of report was provided to Administrator.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Shannon Diegoruelas
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2022
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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