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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803631
Report Date: 12/14/2021
Date Signed: 12/14/2021 01:08:25 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:
12/14/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Licensee, Vilma RichardsonTIME COMPLETED:
01:18 PM
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Licensing Program Analysts Victoria Willis and Caitlynn Felias arrived unannounced to conduct a Case Management inspection and met with Licensee, Vilma Richardson.

LPAs are conducting a health and safety inspection. Licensee has decided to allow for applicant Lacayo Genet, LLC to take over this facility. Currently, Licensee is working with Melissa Genet and William Lacayo to ensure resident's safety and provide care and supervision.

LPAs met with Licensee and spoke with Applicant, Melissa Genet to obtain an update on the Change of Ownership. Per Licensee, they are removing their personal items from the facility but are remaining at the facility to provide care to the residents. Per conversation with Melissa Genet, she is passing medication for this facility and assisting with some Administrator duties in anticipation of their application being approved.

The local fire department is waiting for the vendor for the sprinkler system to conduct an inspection prior to approving the fire clearance. The vendor is scheduled to complete inspection on December 22, 2021.

The department is also waiting for the Administrator Certification renewal for Melissa Genet LPA Willis will follow up regarding items needed.

Based on LPA observations utilities are working, facility appears clean and facility has sufficient food supplies.

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: 12/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2021
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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