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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803631
Report Date: 09/03/2021
Date Signed: 09/03/2021 11:12:18 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
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 LODGEFACILITY NUMBER:
496803631
ADMINISTRATOR:RICHARDSON, VILMAFACILITY TYPE:
740
ADDRESS:611 CHERRY CREEK ROADTELEPHONE:
(707) 894-4615
CITY:CLOVERDALESTATE: CAZIP CODE:
95425
CAPACITY:10CENSUS: 5DATE:
09/03/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Licensee, Vilma RichardsonTIME COMPLETED:
11:30 AM
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Licensing Program Analyst Willis arrived unannounced to conduct a Case Management inspection and met with Licensee, Vilma Richardson.

LPA is following up on plan of corrections from complaint investigations as well as the current status of the facility.
LPA has returned to address citations issued on August 13, 2021. During this visit LPA observed that some boards on the back deck have been replaced or repaired but there are some that still need to be secured. The remaining unsecured boards do not appear to be an immediate risk. Licensee will contact the landlord to have the additional boards secured. Per Licensee, there is only one resident who uses the back deck for one walk per day. Licensee agreed to accompany resident on their walk to ensure resident safety. Per conversation with Licensee, she checked for nests around the facility and did not find any and indicated that wasps/yellow jackets only come out when there is food. The items that were previously stored on the deck have been removed. LPA reviewed the Centrally Stored Medication Log and Licensee has made updates. LPA also followed up with Licensee regarding the deficiency cited July 28, 2021 where a resident's responsible party was not refunded per regulation. The deficiency has not been cleared. Per Licensee, due to only having five residents, they are not financially able to refund resident's responsible party.

LPA discussed the current status of the facility with the Licensee. Licensee was issued an eviction letter dated June 19, 2021 with notice to vacate the property August 1, 2021 but the landlord agreed to extend the vacancy to September 8, 2021. Parties will continue to communicate to ensure residents' health, safety and personal rights.

Civil penalties are being assessed today in the amount of $2,100.00 for failure to correct deficiency and will continue to run at $100.00 per day until corrected.

No additional deficiencies were cited.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria WillisTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2021
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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