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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803143
Report Date: 10/11/2022
Date Signed: 10/11/2022 01:25:39 PM


Document Has Been Signed on 10/11/2022 01:25 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



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: 5DATE:
10/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Licensee/Administrator, Kristi ShehanTIME COMPLETED:
01:35 PM
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Licensing Program Analyst (LPA) Victoria Bertozzi 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 the screening area. Facility continues to screen visitors per CCL guidance. LPA initiated a walk-through of the facility around 11:45 am and observed the following: Facility has COVID-19 posters throughout that include hand washing signs in bathrooms. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is located throughout common areas of the facility. Observed staff had masks on during this visit. Commonly touched surfaces are disinfected three times per day, once on each shift. Facility maintains documentation of staff and resident daily temperatures.

Facility has a designated visitation area outside and is allowing for visitation in resident rooms per CCL guidance. Staff continue to receive training on infection control and donning and doffing of Personal Protective Equipment (PPE) and have been N95 fit tested. LPA and Licensee discussed visitation and activities.

Facility has submitted and CCL has reviewed their Covid Mitigation Plan. Facility has more than a 30 day supply of PPE including but not limited to masks, gowns, and hand sanitizer. Facility maintains a 30 day supply of medication. Fire extinguisher was fully charged and last serviced June 2021. Facility's fire extinguisher vendor recently changed ownership so annual servicing was delayed. Licensee made contact with company during inspection and scheduled a service date. Carbon Monoxide and smoke detectors were tested and operational.

Continued on LIC809C

SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria BertozziTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2022
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 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: VILLAS AT CLOVERDALE, THE
FACILITY NUMBER: 496803143
VISIT DATE: 10/11/2022
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Continued from LIC809C

Licensee and LPA discussed their Emergency Disaster Plan and Infection Control Plan.



Licensee/Administrator to submit updates of the following documents by 11/11/2022:
LIC 308 Designated Administrator (If applicable)
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan (review and update if changes)

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

DATE: 10/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2022
LIC809 (FAS) - (06/04)
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