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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803631
Report Date: 06/11/2021
Date Signed: 06/14/2021 10:40:53 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: DATE:
06/11/2021
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Licensee, Vilma RichardsonTIME COMPLETED:
11:30 AM
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Regional Manager, Carla Nuti-Martinez, Licensing Program Manager Hope DeBenedetti, and Licensing Program Analyst Victoria Willis met with Licensee, Vilma Richardson to conduct an Informal Conference.

Parties discussed areas of concern regarding finances related to the Control of Property for the facility and status of Liability Insurance. An investigation conducted by CCL revealed that facility is having financial issues resulting in staff and rent not being paid. Facility was recently issued a three day eviction and is not abiding by their lease or regulation as they do not currently have Liability Insurance. Per conversation with Licensee, they are paying rent today and will complete documents requested by the liability insurance company today, as well.

Parties also discussed the Emergency Disaster Plan for the facility reminding the Licensee that they may not be able to depend on the fire department for evacuation. Licensee did confirm that they have enough vehicles and staff that can drive available at all times in the case of evacuation.

Licensee agreed to be a part of the Technical Support Program and CCL staff will initiate that request..

CCL has requested the following by Saturday, 6/12/2021:
  • Proof that rent for June 2021 has been paid
  • Current Certificate of Liability Insurance


CCL has requested the following by Thursday, 6/17/2021:
  • Licensee compliant with the active audit and provide requested documentation to auditor
  • Most recent Emergency Disaster Plan
  • Licensee’s plan of how they will meet administrative and financial obligations within required time frames

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: 06/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2021
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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