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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803631
Report Date: 06/11/2021
Date Signed: 06/14/2021 10:44:11 AM



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
02/17/2021 and conducted by Evaluator Victoria Willis
COMPLAINT CONTROL NUMBER: 21-AS-20210217135711
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
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Licensee, Vilma RichardsonTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Facility is in financial distress
Food is expired
INVESTIGATION FINDINGS:
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Licensing Program Analyst Willis met with Licensee, Vilma Richardson to deliver findings regarding the about-mentioned allegations.

During investigation LPA conducted interviews, reviewed documents and made observations.
Facility is in financial distress – Complaint alleges that the facility is under financial distress resulting in staff not being paid timely. Evidence obtained during investigation show that rent was unpaid for multiple months. Interview with Licensee indicated other instances of financial distress including but not limited to a payment plan with a utility company, need for a personal loan and inability to pay rent timely due to not having adequate reserves. Other interviews confirmed that staff were not always paid timely.
Food is expired – Complaint alleges that the Licensee brings expired food into the facility. Photos provided to CCL by a witness show that facility had expired cheese in refrigerator.

The allegations that facility is in financial distress and that food is expired is Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.
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: 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.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
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
02/17/2021 and conducted by Evaluator Victoria Willis
COMPLAINT CONTROL NUMBER: 21-AS-20210217135711

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
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Vilma Richardson, LicenseeTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Insufficient staffing
Facility is not maintaining resident record
Medical Records were not provided to Responsible Party
Neglect/Lack of Supervision
INVESTIGATION FINDINGS:
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Licensing Program Analyst Willis met with Licensee, Vilma Richardson to deliver findings regarding the about-mentioned allegations.

During investigation LPA conducted interviews, reviewed documents and made observations.

Insufficient staffing – Complaint alleges that there is not always enough staff to provide for care needs such as showering. While some interviews indicated that there wasn’t sufficient staff at all times, other interviews denied that there was lack of sufficient staffing. Staff appeared adequate during LPA visits dated 4/14/2021 and 5/14/2021.

Facility is not maintaining resident record; Medical Records were not provided to Responsible Party – Complaint alleges that Licensee did not maintain resident vaccination records and the vaccination records ended up in the dumpster where a staff found and retrieved them. Additional interviews denied knowledge of the situation with the vaccination cards. The cards were ultimately found and provided to the responsible party, per interviews.

Continued on LIC9099C
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 21-AS-20210217135711
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: 06/11/2021
NARRATIVE
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Continued from LIC9099C

Neglect/Lack of Supervision – Complaint alleges that a resident eloped the facility and was injured. CCL has not received a report of the alleged incident and police/ambulance reports did not indicate a call to service for elopement or injury. LPA was unable to obtain additional information regarding the alleged incident.

A finding that the complaint allegations that facility has insufficient staffing. facility is not maintaining resident record, that Medical Records were not provided to Responsible Party and that there was Neglect/Lack of Supervision was unsubstantiated meaning that although the allegation may have happened there is not a preponderance of evidence to prove that the allegation occurred. We have therefore dismissed the complaint.
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
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 21-AS-20210217135711
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: 06/11/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/12/2021
Section Cited
CCR
87213
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87213 Finances Licensee shall have a financial plan that conforms to the requirements of Section 87155, Application for License, and that assures sufficient resources to meet operating costs for care of residents; shall maintain adequate financial records; and shall submit such financial reports as may be required upon the written request of CCL...
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Licensee agrees to submit proof of paid rent for June 2021 and Liability insurance by POC due date, 6/12/2021.

Additionally, Licensee agrees to submit requested financial records per auditor's Engagement Letter by POC due date, 6/17/2021
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CCL reserves the right to reject any financial report and to request additional information or examination including interim financial statements. This requireement has not been met as evidenced by: Per interviews and document review, Licensee is having financial issues. This is an immediate risk to health and safety of residents.
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Type B
06/17/2021
Section Cited
CCR
87555(a)
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87555 General Food Service Requirements (a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful
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Licensee agrees to submit most recent grocery store receipt(s) for facility by POC due date, 6/17/2021.
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manner. This requireement has not been met as evidenced by: Per interviews and review of pictures, expired cheese was in the refrigerator, This is an immediate risk to health and safety of residents.
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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: 06/11/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5