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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803631
Report Date: 12/09/2021
Date Signed: 12/09/2021 12:22:16 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:
12/09/2021
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Licensee, Vilma RichardsonTIME COMPLETED:
12:31 PM
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Licensing Program Analysts (LPA) Willis and Felias arrived unannounced to conduct a Case Management - Legal/Non-Compliance visit and met with Licensee, Vilma Richardson.

LPAs are following up regarding a letter received by the department from the licensee indicating that they are surrendering their license and plan to allow the applicants, Lacayo Genet, LLC to take over operation of the facility. LPA spoke with Licensee, Vilma Richardson and Applicants, William Lacayo and Melissa Genet. Per conversation with Licensee, they have notified residents and/or their responsible parties by letter. LPA was also provided a copy of the letter. LPA will follow up with responsible parties.
Per conversation with both parties, Melissa is prepared to provide care and supervision to the two remaining residents which includes passing medication. A third resident, who is related to the current Licensee, is planning to move though a date has not been decided. William is prepared to provide care and supervision on the NOC shift, if necessary. Licensee plans to stay at the facility until licensure but will start to remove their personal items and agrees to work with the applicants to ensure residents are provided care and supervision per regulation. LPA provided paperwork to Licensee to associate William to this facility and Licensee agrees to send completed paperwork to LPA prior to William working in the facility. Melissa is already associated. Current Licensee is okay with William and Melissa assuming some operation of the facility until licensure but understands that she is still the Licensee and is responsible for the facility including but not limited to, ensuring all utilities are working, facility has sufficient food and that resident's are cared for per their care plans. During this inspection food is sufficient and utilities were working.
LPA also discussed with Licensee that all caregivers who are passing medication must have documentation that they have been trained per regulation. Licensee stated that they understood.
LPA had Licensee sign the reports for the Non-Compliance Conference that occurred via video conference on November 30, 2021 as they had not yet been returned by the licensee.

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

DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021
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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