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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803631
Report Date: 12/02/2021
Date Signed: 12/02/2021 03:36:42 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/30/2021 and conducted by Evaluator Victoria Willis
COMPLAINT CONTROL NUMBER: 21-AS-20211130102817
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
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Caregiver, Celina Alonzo Juarez, Staff Morgan AndrewsTIME COMPLETED:
03:50 PM
ALLEGATION(S):
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Insufficient staffing
Resident records are not current
Facility is in disrepair
INVESTIGATION FINDINGS:
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Licensing Program Analysts Willis and Gonzalez-Campos arrived unannounced to conduct a complaint investigation and met with Caregiver, Celina Alonzo. Licensee, Vilma Richardson was not at the facility but was available by phone. Staff, Morgan Andrews arrived later and Licensee gave permission for him to sign reports.

LPAs conducted interviews, reviewed records and made observations.

Insufficient staffing - Complaint alleges that facility does not have sufficient staff to meet the care needs of residents resulting in a resident being sent to the hospital and not being able to return because staff was not sufficient to care for them. Resident was admitted into another residential care facility. Upon arrival, LPAs observed one staff on duty for three residents, one who is a total assist with transferring. LPA observed staff take medication to a resident in their room.

Continued on LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria WillisTELEPHONE: (707) 588-5087
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 8
Control Number 21-AS-20211130102817
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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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Continued from LIC9099

Later, LPA observed the medication was left on the resident's bedside table despite resident's Physician's Report indicating that resident was unable to store or administer their own medication. Facility was unable to provide proof of medication training for staff. Deficiency for staff training and leaving medication accessible to resident is being cited on a separate case management.

Resident records are not current - LPA review of resident records showed that at least one of five residents did not have an Admission Agreement in their file and at least one of five residents did not have an accurate Centrally Stored Medication log.

Facility is in disrepair - Complaint alleges that facility has trash and debris all over the facility. LPA observed multiple boxes on the outside patio, cans of paint and cleaning supplies. Upon entering a resident's room, LPA smelled cat feces and observed that the litter box had cat feces and cat urine (photo on file). LPA requested that caregiver clean the box, which they did. Various vacant rooms in facility had items throughout including a pole used to attach to a paint roller, walkers, wheelchairs and commodes. One room had linens folded on a bed and many rooms appeared to be being used as storage. Two commodes were also observed by LPA in the outdoor seating area at the entrance to the facility.

The allegations that facility has Insufficient staffing, Resident records are not current and Facility is in disrepair were Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

A Civil Penalty in the amount of $250 was issued for a repeating the same deficiency in a 12 month period.

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.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria WillisTELEPHONE: (707) 588-5087
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
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 21-AS-20211130102817
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 B
12/10/2021
Section Cited
CCR
87506(a)
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87506(a) Resident Records. A separate, complete, and current record shall be maintained for each resident in the facility, readily available to facility staff and to licensing agency staff and shall contained specified information. This requirement has not been met based on LPA file review showing that at least one of five residents
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Licensee agrees to review files and ensure they are updated with required paperwork and submit self-certification that they were completed to CCL by POC due date 12/10/2021
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did not have an Admission Agreement in their file and at least one of five residents did not have an accurate Centrally Stored Medication log. This is a potential risk to the health and safety of residents 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: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria WillisTELEPHONE: (707) 588-5087
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
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 21-AS-20211130102817
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
CCR
87411(a)
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87411 Personnel Requirements - General
(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the
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Licensee agrees to submit an updated LIC500 and updated care plans for all residents showing that staffing is sufficient to care for the needs of the residents by POC due date, 12/2/2021.
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extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. Requirement has not been met as evidenced by LPA observation and file review showing that there was only one staff for three residents, one who is a total assist and only staff does not have documented training.
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Type B
12/06/2021
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement has not been met as evidenced by
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Licensee agrees to remove/organize items and submit self-certification that facility is safe, sanitary and in good repair by POC due date, 12/6/2021. LPA will return at a later date.

A Civil Penalty in the amount of $250 was issued for a repeating the same deficiency in a 12 month period.
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LPA observation that resident rooms smelled of cat feces, multiple boxes on the outside patio. Various vacant rooms appeared to be being used as storage with walkers, wheelchairs and commodes in rooms and two commodes in an outdoor seating area. This is a potential risk to residents 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: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria WillisTELEPHONE: (707) 588-5087
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
LIC9099 (FAS) - (06/04)
Page: 8 of 8