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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 480102469
Report Date: 05/20/2022
Date Signed: 05/23/2022 10:37:08 AM

Document Has Been Signed on 05/23/2022 10:37 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:CLARK-RO HOMEFACILITY NUMBER:
480102469
ADMINISTRATOR:SKILLMAN, C.W. & R.LFACILITY TYPE:
735
ADDRESS:242 CORTLANDTELEPHONE:
(707) 642-9361
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 5CENSUS: 3DATE:
05/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Rosie Skillman, LicenseeTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. Infection Control inspection for this facility. LPA called facility land line phone with no response. No staff or clients appeared to be at the facility at the time of visit. LPA contacted Licensee, Rosie Skillman who along with House Manager, Tracy Skillman who arrived at the facility at approximately 2:00PM. There are 3 clients in care none of which were present at the time of visit.

LPA arrived at the facility and had temperature checked and logged. LPA continued with a tour of the facility with Licensee; facility was found at a comfortable temperature. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 5/9/2022 at the time of the visit. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations clients in care. Food stored in the kitchen refrigerator were stored properly as per regulations on this day at the time of the visit. There was a supply of linens, hygiene products and paper products available for clients located in the hallway. All client’s bedrooms have lighting & appropriate furnishings. LPA observed a client C1's drawer removed from the bedroom due to damage. House Manager stated that it was removed a week prior and will be replaced. C1 has additional closet space with drawers located in them. Hot water measured at 108.6 degrees F which is within Title 22 regulations of 105 to 120 degrees F in faucets used by clients. All staff have updated 1st Aid & CPR Training on file.

During the tour LPA observed a large dried stain located on C1's bedroom floor and requested for staff to conduct general cleaning of client bedrooms. C1's bedroom also has missing window screen and damage on the bedroom door frame which requires repair. In addition, LPA observed multiple debris and collection of plastic bottles located along the sides of the backyard.

Continued onto LIC809(C)**
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 05/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/20/2022
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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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: CLARK-RO HOME
FACILITY NUMBER: 480102469
VISIT DATE: 05/20/2022
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LPA requested the following documents be sent to CCL by COB 5/27/2022:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Copy of Administrator Certificate(s)
Copy of Certificate of Liability Insurance

Infection Control:
Facility has submitted a mitigation program plan which has been approved. All clients have been vaccinated with no reported or observed symptoms. Posters have been placed at the front door, and facility has a station at main entrance with a sign in, hand sanitizer and other items designated for visitors and staff. Staff are screened for temperature and symptoms on a daily basis and clients are screened on a daily basis.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Appeal Rights Given.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/23/2022 10:37 AM - It Cannot Be Edited


Created By: Dominic Tobola On 05/20/2022 at 03:26 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: CLARK-RO HOME
FACILITY NUMBER: 480102469

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)

80087(a) Buildings & Grounds. The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 3 out of 3 items which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed bedroom door frame and window screen in C1's bedroom in need of repair. C1's bedroom also observed to have large stain along floor. LPA observed debris and plastic bottles along the side of the faciltiy in need of disposal.
POC Due Date: 06/03/2022
Plan of Correction
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Licensee agrees to repair items described and general cleaning of client bedrooms. Licensee to provide proof of corrections; photo evidence to CCL by POC due date 6/3/2022.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Kimberley Mota
LICENSING EVALUATOR NAME:Dominic Tobola
LICENSING EVALUATOR SIGNATURE:
DATE: 05/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2022


LIC809 (FAS) - (06/04)
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