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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803143
Report Date: 11/19/2021
Date Signed: 11/19/2021 10:38:47 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:VILLAS AT CLOVERDALE, THEFACILITY NUMBER:
496803143
ADMINISTRATOR:SHEHAN, KRISTIFACILITY TYPE:
740
ADDRESS:214 W. THIRD STREETTELEPHONE:
(707) 894-3119
CITY:CLOVERDALESTATE: CAZIP CODE:
95425
CAPACITY:6CENSUS: 6DATE:
11/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Licensee/Administrator, Kristi ShehanTIME COMPLETED:
10:48 AM
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Licensing Program Analyst (LPA) Victoria Willis arrived unannounced to conduct an Annual Required inspection and met with Licensee/Administrator, Kristi Shehan. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival, LPA observed a notice on the front door which outlined the facility's visitation and Covid-19 screening policy. Upon entry into the facility LPA's temperature was taken by the Licensee and LPA was asked to fill out a questionnaire with standard Covid-19 screening questions. LPA initiated a walk-through of the facility around 9:35pm and observed the following: Facility has COVID-19 posters throughout that includes hand washing and cough etiquette signs in bathroom. Hand sanitizer is located throughout common areas of the facility. Other hand-washing supplies were also observed in bathroom. LPA confirmed with Licensee that they are conducting vaccine verification for visitors per Provider Information Notice (PIN) 21-40-ASC. Facility was a comfortable temperature and exits were free from obstructions. Observed staff had masks on during this visit. Commonly touched surfaces are disinfected three times per day, on each shift. Facility maintains documentation of staff and resident daily temperatures.

Facility has a designated visitation area outside. Visitation is allowed inside the facility after vaccination verification or proof of a negative test within 72 hours, per current CCL guidance. Staff have completed PPE training and have been N95 fit tested.

Facility has submitted and CCL has reviewed their Covid Mitigation Plan. Facility has more than a 30 day supply of Personal Protective Equipment (PPE) including but not limited to masks, gowns and hand sanitizer. Facility maintains a 30 day supply of medication.

Licensee and LPA discussed their Emergency Disaster Plan. Fire extinguishers have been serviced within the last year. Facility recently had an inspection by the local fire department. No issues noted.



LPA requested the updated lease from Licensee.

No deficiencies cited during this inspection.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria WillisTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2021
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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