496803631-11-3-2021-21-AS-VWIS-C8ETDB-20211103143805

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803631
Report Date: 11/03/2021
Date Signed: 11/03/2021 02:38:17 PM

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 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: 5	DATE:	11/03/2021
TYPE OF VISIT:	POC	UNANNOUNCED	TIME BEGAN:	09:17 AM
MET WITH:	Licensee, Vilma Richardson		TIME COMPLETED:	02:50 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 Analyst Willis arrived unannounced to conduct a Plan of Correction visit and met with Licensee, Vilma Richardson. Upon arrival LPA confirmed with Licensee that they are following PIN 21-40-ASC and verifying vaccination for visitors who seek indoor visitation. Staff had masks on during inspection. LPA and Licensee discussed the status of the corrections for deficiencies that were previously cited. Licensee previously provided the First Aid and CPR Certification for her and her staff. That deficiency is cleared. LPA observed that the fire alarm system was serviced by the vendor on October 2021, however, the fire extinguishers have not yet been serviced. Per Licensee, they have to take the fire extinguishers to be serviced and planned on taking them today. Per conversation with Licensee, they have contacted the Secretary of State and were told verbally over the phone that they needed to send payment for their annual fee and then they would be provided additional information on how to make their LLC current. Licensee was unable to provide the name of the individual who they spoke with. Licensee provided LPA with a copy of the check made out to the Secretary of State but was unable to provide any additional information. Continued on LIC809C

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Willis	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 11/03/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/04/2021 Section Cited	1 2 3 4 5 6 7	(b) If the licensee is a corporation or an association, the governing body shall be active, and functioning in order to assure accountability. This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above because their LLC has been suspended per the Secretary of State website which poses
	8 9 10 11 12 13 14	an immediate health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14
Type B 11/17/2021 Section Cited	1 2 3 4 5 6 7	(b) (1) The department shall adopt regulations to require staff members of RCFEs who assist residents with personal ADLs to receive appropriate training. Training shall consist of 40 hrs of training. Staff member shall complete 20 hrs, including 6 hrs specific to dementia care & 4 hrs specific to postural supports, restricted health conditions, and hospice
	8 9 10 11 12 13 14	care before working independently with residents. Remaining 20 hs shall include 6 hrs specific to dementia care & shall be completed within the first 4 wks of employment. The additional 16 hours shall be hands-on training.	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: 11/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2021

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
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: CLEARWATER LODGE	FACILITY NUMBER: 496803631
	VISIT DATE: 11/03/2021

NARRATIVE

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Continued from LIC809

LPA reviewed caregiver training that was conducted from October 10, 2021 through October 25, 2021 which totaled 18 hours. Training hours are not sufficient to fulfill the regulation requirement with two hours completed pertaining to dementia, four hours pertaining to medication, and two hours on restricted health conditions. LPA previously provided written direction on what hours are required and in what areas but LPA review of checklist revealed that Licensee is using a checklist that is not current with the training required as of January 1, 2016. LPA provided an additional handout outlining training requirements. Training checklist did not show 16 total hours of hands on training (shadowing) that is required by regulation.

LPA reviewed the training materials used by the Licensee and observed that materials covered dementia, hospice and medication but did not cover other required areas including but not limited to postural supports, restricted health conditions, personal rights or assistance with activities of daily living. Facility does not have an organized training program and training materials appeared to be from multiple sources. It was not always clear how updated the materials were. Per conversation with Licensee, they are changing to an electronic training system.

The following items are being re-cited or a Civil Penalty is being issued:

CCR 87411(d) - Civil Penalty is being issued in the amount of $200 for not providing on the job training as required by regulation by POC due date, 11/1/2021.
CCR 87203 - Civil Penalty is being issued in the amount of $1,300 due to Licensee's failure to have fire extinguishers serviced by POC due date 10/20/2021.
CCR 87412(c) - Civil Penalty is being issued in the amount of $200 due to Licensee's failure to provide CCL with training materials that are compliant with regulation by POC due date, 11/1/2021
H&S 1569.69(a) - Civil Penalty is being issued in the amount of $200 for not providing medication training as required by regulation by POC due date, 11/1/2021
87205(b) - Deficiency re-cited due to facility not correcting deficiency by POC due date, 10/22/2021
1569.625(b) - Deficiency re-cited due to facility not correcting deficiency by POC due date, 10/22/2021

Civil Penalties will continue to accrue daily until deficiencies are corrected.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Willis	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2021

LIC809 (FAS) - (06/04)

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