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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803631
Report Date: 06/24/2021
Date Signed: 06/24/2021 11:34:00 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: 8DATE:
06/24/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:59 AM
MET WITH:Licensee, Vilma RichardsonTIME COMPLETED:
11:45 AM
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Licensing Program Analysts Victoria Willis and Erik Gonzalez-Campos arrived unannounced to conduct a Plan of Correction visit and met with Licensee, Vilma Richardson.

During inspection, LPAs received confirmation from the insurance broker that facility has Liability Insurance as of June 22, 2021 and a Certificate of Liability Insurance will be sent to the Licensee today. Licensee also provided LPAs with their updated Emergency Disaster Plan and previously provided grocery receipts for the last three months which was requested by LPA and the CCL Auditor. Licensee has also provided proof of payment for June, 2021.

Licensee stated that they have spoken with the CCL Auditor and are complying with their request for documents. LPA will follow up with auditor to confirm.

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: 06/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2021
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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