496803631-12-22-2021-21-AS-CMAZ-C9ZTYZ-20211224140935

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496803631
Report Date: 12/22/2021
Date Signed: 12/22/2021 03:30:37 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 LODGE		FACILITY NUMBER:	496803631
ADMINISTRATOR:	RICHARDSON, VILMA		FACILITY TYPE:	740
ADDRESS:	611 CHERRY CREEK ROAD		TELEPHONE:	(707) 894-4615
CITY:	CLOVERDALE	STATE: CA	ZIP CODE:	95425
CAPACITY:	10	CENSUS: 2	DATE:	12/22/2021
		UNANNOUNCED	TIME BEGAN:	02:31 PM
MET WITH:	Staff, Melissa Genet		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Neglect/lack of supervision resulted in resident in care sustaining pressure injury
Neglect/lack of supervision staff not meeting residents hygiene needs
Staff do not allow resident out of room
Facility does not have hygiene products in resident restroom

INVESTIGATION FINDINGS:

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Licensing Program Analysts Victoria Willis and Caitlynn Felias arrived unannounced to deliver findings regarding the above Complaint Allegations and met with staff, Melissa Genet. Licensee was unavailable during inspection.

Neglect/lack of supervision resulted in resident in care sustaining pressure injury – Complaint alleges that a resident was sent to the hospital with unstageable pressure injuries. File review and interview indicated that resident was observed by caregiver(s) as having a rash. Caregiver notified the home health nurse who assessed resident and noted “moisture related skin damage” adding that due to rash, they were unable to assess for pressure injuries. Per document review, the “wound” was classified as a fungal rash and did not indicate that resident had an unstageable pressure injury.

Continued on LIC9099

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Willis	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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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: 12/22/2021

NARRATIVE

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Continued from LIC9099

Staff do not allow resident out of room – Complaint alleges that there is a resident who hasn’t left their room in a long time, not even to go to the dinner table. Per interview, the resident goes outside when their family visits. Per interview, the caregivers do not take the resident outside so the resident eventually stopped asking. Interview with staff indicated that resident was taken outside 1 to 2 times per week. Staff stated they offered to take resident outside but sometimes the resident refused.

Neglect/lack of supervision staff not meeting resident’s hygiene needs – Complaint alleges that facility is not assisting resident with brushing their teeth. Per LPA observation and interview, resident R1 keeps a packet of disposable toothbrushes that has toothpaste already on the brush and does not need water on their accessible bedside table. Per interview, R1 is able to use the toothbrush themselves.

Facility does not have hygiene products in resident restroom – Complaint alleges that the facility does not have paper towels and soap in the bathrooms. During the December 2, 2021 visit and today's visit, LPA observed towels and soap in bathroom.

A finding that the complaint allegations Neglect/lack of supervision resulted in resident in care sustaining pressure injury, Neglect/lack of supervision staff not meeting residents hygiene needs, Staff do not allow resident out of room and Facility does not have hygiene products in resident restroom was unsubstantiated meaning that although the allegations may have happened there is not a preponderance of evidence to prove that the allegations occurred.

No deficiencies cited during this visit.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Willis	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021

LIC9099 (FAS) - (06/04)

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