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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803631
Report Date: 12/02/2021
Date Signed: 12/02/2021 03:35:41 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 LODGEFACILITY NUMBER:
496803631
ADMINISTRATOR:RICHARDSON, VILMAFACILITY TYPE:
740
ADDRESS:611 CHERRY CREEK ROADTELEPHONE:
(707) 894-4615
CITY:CLOVERDALESTATE: CAZIP CODE:
95425
CAPACITY:10CENSUS: 3DATE:
12/02/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Staff, Celina Alfonso Juarez and Morgan AndrewsTIME COMPLETED:
03:50 PM
NARRATIVE
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Licensing Program Analysts (LPA) Victoria Willis and Erik Gonzalez Campos arrived unannounced at approximately 9:00 AM to conduct a case management inspection. Licensee/Administrator Vilma Richardson was not present for the inspection but was available by phone. LPAs met with staff, Celina Alfonso Juarez. Staff, Morgan Andrews arrived later.

Staff took LPA temperatures and requested they sign in. LPA took a tour of the kitchen and observed the following in the pantry; two boxes of expired cereal, two jars of expired peanut butter, and one box of expired granola mix. LPA observed the following in the refrigerator; one bag of raw chicken breast with a handwritten date of 11/21/2021, one container of bread pudding with a handwritten date of 11/24/2021, one bowl of pasta with a hand written date of 11/28/2021, and one bowl of oatmeal dated 11/01/2021. LPA also observed a container of raw chicken marked with a date of 12/13/2021. LPA took photos of observation. Staff explained that the raw chicken was placed in the freezer on 11/21/2021 but taken out to defrost on 12/01/2021. Staff indicated other items were labeled erroneously and inconsistently by another staff.

During tour of the facility LPA observed an unlocked closet which contained cleaning supplies. LPA observed paint cans on the back patio area. Medication was observed unattended in a resident's bedroom. Licensee has not returned signed noncompliance conference reports from conference on 11/29/2021 so LPA left reports for Licensee signature. Licensee to ensure signed reports are returned to CCL by 12/2/2021.

LPAs are requesting COVID testing documents for unvaccinated staff per PIN 21-44 by 12/2/2021.

A civil penalty is being issued in the amount of $250.00 for a repeat violation of the same deficiency within a 12 month period.

Continued on LIC 809C
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 5
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: 12/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/02/2021
Section Cited

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87705(f) Care of Persons with Dementia-The following shall be stored inaccessible to residents with dementia: Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances
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such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by: Based on LPAs observation, an unlocked closet was observed containing supplies and paint was observed accessible on patio area which poses an immediate health and safety risk to residents in care.
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Type A
12/02/2021
Section Cited

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87555(b)(9) General Food Service Requirements. Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service.
This requirement is not met as evidenced by: Based on LPAs observation,
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 the facility failed to dispose of expired cereal boxes and peanut butter in the pantry. Facility also failed to dispose of food by labled date in the fridge which poses an immediate health and safety risk to residents in care.
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food is kept beyond its expiration. Certification that all expired food has been disposed of & proof of training to be submitted to CCL by POC date of 12/03/2021.
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: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 12/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2021
LIC809 (FAS) - (06/04)
Page: 2 of 5
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: 12/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/03/2021
Section Cited

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1569.69 Employees assisting residents with self-administration of medication; training requirements (a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following traning requirements
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This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above in one out of one staff not having required training for assisting residents with self-administrator of medication which poses a potential health, safety or personal rights risk to persons in care.
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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: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 12/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2021
LIC809 (FAS) - (06/04)
Page: 3 of 5
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: 12/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/03/2021
Section Cited

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87465(h)(2) Incidental Medical and Dental Care Services. Centrally stored medications shall be kept in a safe locked place that is not accessible to persons other than employees responsible for the supervision of the medication. This requirement was not evidenced by:
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Based on LPA observation, in one of the resident's bedrooms,medications were observed unattended in a cup which was accessible to residents which poses an immediate risk to residents in care.
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Type A
12/03/2021
Section Cited

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1569.625 Staff training; (b)(1) The department shall adopt regulations to require staff of RCFEs who assist residents with personal ADLs to receive appropriate training. Training shall consist of 40 hrs. Staff member shall complete 20 hrs, including 6 hrs specific to dementia care, & 4 hrs specific to postural supports , restricted health conditions, &
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hospice care, before working independently with residents. Remaining 20 hrs shall include 6 hrs specific to dementia care & shall be completed within the first 4 wks of employment. Additional 16 hrs shall be hands-on training. Requirement has not been met as evidenced by file review showing that only staff on duty is not trained per regulation.
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A civil penalty is being issued in the amount of $250.00 for a repeat violation of the same deficiency within a 12 month period.
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: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 12/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2021
LIC809 (FAS) - (06/04)
Page: 4 of 5
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: 12/02/2021
NARRATIVE
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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.

Exit interview conducted over the phone with Licensee who allowed for staff to sign report. A copy of this report printed for the facility.

Reports signed by staff, Morgan Andrews. Licensee gave verbal permission over the phone for staff to sign.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2021
LIC809 (FAS) - (06/04)
Page: 5 of 5