<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803631
Report Date: 11/30/2021
Date Signed: 12/09/2021 03:59:56 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: 5DATE:
11/30/2021
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Licensee, Vilma Richardson and Back-up Administrator, Kristi ShehanTIME COMPLETED:
04:00 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
Regional Manager, Carla Nuti-Martinez, Licensing Program Manager Hope DeBenedetti, and Licensing Program Analyst Victoria Willis met with Licensee, Vilma Richardson and Back-up Administrator, Kristi Shehan to conduct a Non-Compliance Conference.

Parties discussed multiple areas of concern including but not limited to the following:
  • Administrator Duties and Plan of Operation
  • Reporting Requirements
  • Financial Concerns
  • Staff Training
  • Insufficient Staffing


Licensee to ensure the following:
  • Licensee will ensure a back-up administrator is hired to ensure facility is in compliance. A duty statement will be included along with the proper paperwork (Copy of current Admin Certificate, LIC500, transfer prints in Guardian).
  • Licensee will ensure LLC is cleared and in good standing
  • Licensee will submit a written plan listing all utilities and plan to ensure all are paid timely.
  • Licensee will ensure all staff are training appropriately.
  • Licensee will submit a copy of the agreement with Kristi Shehan.
  • Licensee will ensure that any changes to Admission Agreements or the Plan of Operation will be submitted to CCL for review
  • Licensee will submit an updated Facility Sketch and LIC200 for any rooms that are being changed from a single room to a double room

No deficiencies were cited during today’s office visit.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria WillisTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2021
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 1