496803631-8-13-2021-21-AS-HDBI-C634BZ-20210819185821

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496803631
Report Date: 08/13/2021
Date Signed: 08/13/2021 01:08:42 PM

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
07/30/2021 and conducted by Evaluator Victoria Willis

COMPLAINT CONTROL NUMBER: 21-AS-20210730122942

FACILITY NAME:	CLEARWATER LODGE		FACILITY NUMBER:	496803631
ADMINISTRATOR:	RICHARDSON, VILMA		FACILITY TYPE:	740
ADDRESS:	611 CHERRY CREEK ROAD		TELEPHONE:	(707) 894-4615
CITY:	CLOVERDALE	STATE: CA	ZIP CODE:	95425
CAPACITY:	10	CENSUS: 4	DATE:	08/13/2021
		UNANNOUNCED	TIME BEGAN:	09:37 AM
MET WITH:	Licensee, Vilma Richardson		TIME COMPLETED:	01:10 PM

ALLEGATION(S):

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Administrator is not able to perform duties
Facility is not maintaining the property

INVESTIGATION FINDINGS:

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Licensing Program Analyst WIllis arrived unannounced to conduct a complaint investigation regarding the above mentioned complaint allegation and met with Licensee, Vilma Richardson.

Complaint alleges that Administrator is not able to perform duties. Review of records revealed that Administrator is not maintaining or supervising the maintenance of records which is a requirement of Administrator duties. Administrator is not ensuring the maintenance of the Centrally Stored Medication Log as required by regulation.

Complaint alleges that the facility is not maintaining the property because there are mattresses being stored on the back deck. LPA observed that mattresses are being stored on the back deck. Additionally.

Continued on LIC9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Willis	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20210730122942

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
	VISIT DATE: 08/13/2021

NARRATIVE

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Continued from LIC9099

LPA observed that there are planks on the deck that need to be replaced and there were multiple wasps and/or yellow jackets that, per interview with Licensee, bother residents when they come out onto the deck. LPA and Licensee discussed closing off the back deck until issues could be resolved. Facility has another outdoor area in the front of the facility that may be used.

The allegations that Administrator is not able to perform duties, and Facility is not maintaining the property 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.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Willis	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2021

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20210730122942

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: 08/13/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/20/2021 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement has not been met as evidenced by: Based on LPA observation. the back deck	1 2 3 4 5 6 7	Licensee plans to make the deck off limits until the area is safe and will have residents use the other outside area. Licensee agrees to remove mattresses and contact the landlord regarding the insects and disrepair of the deck by POC due date, 8/20/2021. LPA will return to observe repairs.
	8 9 10 11 12 13 14	has mattressed being stored, unsecured wood planks and insects flying around that are creating an unsafe environment for the residents. This is a potential risk to the health ans safety of residents in care.	8 9 10 11 12 13 14
Type B 08/20/2021 Section Cited CCR 87405(d)(3)	1 2 3 4 5 6 7	87405 Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. (3) Ability to maintain or supervise the maintenance of financial and other records. This requirement	1 2 3 4 5 6 7	Licensee agrees to update the Centrally Stored Medication Log for all residents by POC due date, 8/20/2021. LPA will return to review.
	8 9 10 11 12 13 14	has not been met as evidenced by: Based on LPA file review, Administrator is not maintaining medication records. This is a potential risk to the health and safety of residents in care.	8 9 10 11 12 13 14

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 DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Willis	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2021

LIC9099 (FAS) - (06/04)

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