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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803143
Report Date: 01/21/2025
Date Signed: 01/21/2025 11:38:09 AM

Document Has Been Signed on 01/21/2025 11:38 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:VILLAS AT CLOVERDALE, THEFACILITY NUMBER:
496803143
ADMINISTRATOR/
DIRECTOR:		WOODWARD, ROSE B.FACILITY TYPE:
740
ADDRESS:214 W. THIRD STREETTELEPHONE:
(707) 894-3119
CITY:CLOVERDALESTATE: CAZIP CODE:
95425
CAPACITY: 6CENSUS: 5DATE:
01/21/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Tabitha Frampton-CaregiverTIME VISIT/
INSPECTION COMPLETED:
11:50 AM
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Licensing Program Analyst (LPA) Alviso arrived unannounced to conduct a continued annual inspection, on 1/21/25 at approximately 9:40am, and met with lead caregiver Tabitha Frampton. LPA observed another caregiver, Erika Nava, on duty during the inspection. Annual review is continued from LPA's inspection date of 12/16/24, see LIC809 report.

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.

LPA reviewed five (5) resident files.

There are no deficiencies cited today.

Exit interview conducted with Erika Nava. Report left with Erika Nava for the Administrator, Rose Woodward.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/21/2025
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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