496803143-12-16-2024-21-AS-DALO-DC23EF-20241216171105

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803143
Report Date: 12/16/2024
Date Signed: 12/16/2024 05:11:15 PM

Document Has Been Signed on 12/16/2024 05:11 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, THE		FACILITY NUMBER:	496803143
ADMINISTRATOR/ DIRECTOR:	WOODWARD, ROSE B.		FACILITY TYPE:	740
ADDRESS:	214 W. THIRD STREET		TELEPHONE:	(707) 894-3119
CITY:	CLOVERDALE	STATE: CA	ZIP CODE:	95425
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	12/16/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:15 AM
MET WITH:	Tabitha Frampton-Caregiver		TIME VISIT/ INSPECTION COMPLETED:	05:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPAs), Alviso and Frank, arrived unannounced to conduct an Annual Required inspection, on 12/16/24 at approximately 11:15am, and met with Tabitha Frampton. LPAs observed another caregiver working at the facility, Erika Nava. Administrator Rose Woodward and Karen Sims, House Manager arrived to meet with the LPAs. Erika Nava stated they were shadowing/training as they were a new hired staff; Erika stated they had left the facility, back in approximately October 2024, and recently was rehired. Facility is fire cleared for six (6) non-ambulatory/bedridden residents. Facility has a required infection control plan. Facility has a required emergency disaster plan. Facility has an approved dementia plan of operation. Hospice waiver approval is for four (4) residents only. LPAs toured the facility. Hot water was checked at 116. degrees Fahrenheit, which is within regulation. The fire extinguisher, one (1), was serviced and tagged as required. All smoke alarms were checked, and all worked, but one (1) made a very low toned alarm, the Administrator agreed to follow-up with the fire equipment service that had recently checked/serviced all alarms and the fire extinguisher. All exit doors had auditory alarms on them. All medications were stored appropriately and locked up per regulations. Sufficient supply of linens, paper products, furnishings, hygiene products, and personal protective equipment (PPE) for use by the facility. The facility was at a comfortable temperature. There was sufficient lighting for residents in all common areas, hallways, bathrooms, and resident rooms. The bathrooms had grab bars, and shower mats/non-slip flooring for residents use. LPAs reviewed six (6) staff files, including training. Continued on LIC809C....

Bethany Moellers	TELEPHONE: (707) 588-5040
Dina Alviso	TELEPHONE: (707) 588-5082
	DATE: 12/16/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024

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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: VILLAS AT CLOVERDALE, THE	FACILITY NUMBER: 496803143
	VISIT DATE: 12/16/2024

NARRATIVE

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LPA is requesting the following documents be updated and submitted by 1/16/25:
LIC308 - Designation of Administrator Responsibility
LIC500 - Personnel Report
LIC610E-Emergency Disaster Plan (ensure to review and update as needed/required)
Infection Control Plan (ensure to review and update as needed/required)
Copy of LIC400 Handling of Client Cash Resources (include copy of surety bond if handling cash)
Copy of Current Liability Insurance
Resident Roster
Copy of current Administrator Certificate.

The following deficiencies were observed, photos obtained by LPAs, during the inspection and will be cited:

LPAs observed cleaners and disinfectants unlocked and accessible to residents in care, found in the kitchen, storage closet, and in an unlocked shed. This deficiency will be cited, 87705(f)(2) Care of Persons with Dementia The following shall be stored inaccessible to residents with dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants, see LIC809D.

Per record reviews, S4 lacked required fingerprint association to the facility prior to working in it. LPA Alviso confirmed with the Licensing office staff that S4 was not associated per check of the Guardian website. This deficiency will be cited, 87355(c)(1)(2) Criminal Record Clearance-A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another, or from Trust Line to a state licensed facility by providing the following documents to the Department: A signed Criminal Background Clearance Transfer Request, LIC 9182 (Rev. 4/02). A copy of the individual's: (A) Driver's license, or (B) Valid identification card issued by the Department of Motor Vehicles, or (C) Valid photo identification issued by another state or the United States government if the individual is not a California resident, see LIC809D. An immediate civil penalty will be assessed in the amount of $600, see LIC421BG.

Per record reviews, S5 was denied an exemption request by the Department; Exemption Denial Letter, dated 5/23/24, went out to the Licensee/Facility at 214 W. Third St., Cloverdale, 95425, notifying Licensee/Administrator of the exemption denial. Review of scheduled days worked/paid showed S5 was last paid 12/7/2024. S5 has been on the work schedule, LPA notified Administrator Rose Woodward and House Manager Karen Sims that S5 is on the facility premises, they were denied an exemption by the Department. 87356(m) Criminal Record Exemption- The Department shall not grant an exemption if the individual has a conviction for any offense specified in Section 1569.17(f)(1) of the Health and Safety Code, see LIC809D.

This annual will be conyinued by the Department at a later date.

California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited. Failure to correct deficiency (s) by due date (s), may result in additional deficiency citations and/or civil penalties being assessed.
Exit interview conducted with the Administrator Rose Woodward. Appeal Rights Provided.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/16/2024 05:11 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

87355(c)(1)(2) Criminal Record Clearance-A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another, or from Trust Line to a state licensed facility by providing the following documents to the Department: A signed Criminal Background Clearance Transfer Request, LIC 9182 (Rev. 4/02). A copy of the individual's: (A) Driver's license, or (B) Valid identification card issued by the Department of Motor Vehicles, or (C) Valid photo identification issued by another state or the United States government if the individual is not a California resident. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record reviews, S4 lacked required fingerprint association to the facility prior to working in it. LPA Alviso confirmed with the Licensing office staff that S4 was not associated per check of the Guardian website. the licensee did not comply with the section cited above in [1} out of [6] staff which poses/posed a potential health, safety or personal rights risk to persons in care. Immediate Civil Penalty of $100 is being assessed today, see LIC421BG.
	POC Due Date: 12/17/2024
	Plan of Correction
1 2 3 4	Administrator to ensure that S4 is associated as required by regulation prior to coming into the facility to work and/or on facility premises. Administrator to access Guardian website to associate S4 to the facility and/or submit required documentation to the licensing office requesting an association of S4. POC due 12/17/24.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Bethany Moellers	TELEPHONE: (707) 588-5040
Dina Alviso	TELEPHONE: (707) 588-5082
	DATE: 12/16/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024

LIC809 (FAS) - (06/04)

Page: 4 of 4

Document Has Been Signed on 12/16/2024 05:11 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

87356(m) Criminal Record Exemption- The Department shall not grant an exemption if the individual has a conviction for any offense specified in Section 1569.17(f)(1) of the Health and Safety Code This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Per record reviews, S5 was denied an exemption request by the Department; Exemption Denial Letter, dated 5/23/24, went out to the Licensee/Facility at 214 W. Third St., Cloverdale, 95425, notifying Licensee/Administrator of the exemption denial. Review of scheduled days worked/paid showed S5 was last paid 12/7/2024. S5 has been on the work schedule, LPA notified Administrator Rose Woodward and House Manager Karen Sims that S5 is on the facility premises, they were denied an exemption by the Department, the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.Immediate Civil Penalty of $500 is being assessed today, see LIC421BG.
	POC Due Date: 12/17/2024
	Plan of Correction
1 2 3 4	Licensee/Administrator to ensure that S5, is not on facility premises and/or working in the facility, they do not have criminal record clearance and were denied an exemption by the Department. Remove S5 from the work schedule and submit written confirmation of having complied with regulations regarding denied exemption/no DOJ fingerprint clearance as required. POC due 12/17/24.

Section Cited

87705(f)(2) Care of Persons with Dementia The following shall be stored inaccessible to residents with dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	LPAs observed cleaners and disinfectants unlocked and accessible to residents in care, found in the kitchen, storage closet, and in an unlocked shed., the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/17/2024
	Plan of Correction
1 2 3 4	Licensee/Administrator to ensure that the facility staff lock all cleaners/disinfectants up at all times, ensuring they are inaccessible to residents in care. Hold an in-service with all staff. Submit proof of inservice training with the staff by 12/23/24. Submit plan of correction in locking up all cleanres/disinfectanta and keeping them inaccessible to residents. POC due 12/17/24.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Bethany Moellers	TELEPHONE: (707) 588-5040
Dina Alviso	TELEPHONE: (707) 588-5082
	DATE: 12/16/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024

LIC809 (FAS) - (06/04)

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