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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803631
Report Date: 11/24/2020
Date Signed: 12/03/2020 08:58:34 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/19/2020 and conducted by Evaluator Victoria Willis
COMPLAINT CONTROL NUMBER: 21-AS-20201119091338
FACILITY NAME:CLEARWATER LODGEFACILITY NUMBER:
496803631
ADMINISTRATOR:RICHARDSON, VILMAFACILITY TYPE:
740
ADDRESS:611 CHERRY CREEK ROADTELEPHONE:
(707) 894-4615
CITY:CLOVERDALESTATE: CAZIP CODE:
95425
CAPACITY:10CENSUS: 9DATE:
11/24/2020
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Licensee, Vilma RichardsonTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Faciltiy staff failing to wear masks/face coverings
INVESTIGATION FINDINGS:
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LPA Willis conducted a Televisit with Licensee, Vilma Richardson due to Covid-19 precautions.

LPA received information that a staff was not wearing a mask while in the facility and another removed their masks while in the dining area which is a common area of the facility. Conversation with Licensee confirmed that staff did remove their mask while in a common area of the facility. On November 13, 2020, licensee failed to protect the personal rights of clients in care to receive safe and healthful accommodations and engaged in conduct inimical to the health, welfare, and safety of clients in care, in that licensee failed to wear face coverings while providing care and supervision to clients in care, in violation of official government orders requiring the wearing of face coverings while working under specified conditions.

The allegation that faciltiy staff is failing to wear masks/face coverings is Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria WillisTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:

DATE: 11/24/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/24/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 21-AS-20201119091338
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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: CLEARWATER LODGE
FACILITY NUMBER: 496803631
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/24/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/25/2020
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(2) To be accorded safe, healthful & comfortable accommodations, furnishings and equipment. This requirement hasn't been met based on interviews indicating that on 11/13/2020 licensee failed to protect
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Licensee agrees to sign up for infection control training provided through the Long Term Care Ombudsman Office and will submit proof of training to CCL by POC due date, 11/25/2020.
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personal rights of clients in care to receive safe & healthful accommodations in that licensee failed to wear face coverings while providing care & supervision to clients in care, in violation of official government orders requiring the wearing of face coverings while working under specified conditions. This is an immediate risk to health & safety of residents.
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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: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria WillisTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:

DATE: 11/24/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/24/2020
LIC9099 (FAS) - (06/04)
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