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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803631
Report Date: 07/08/2021
Date Signed: 07/08/2021 12:05:21 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: 7DATE:
07/08/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Licensee, Vilma RichardsonTIME COMPLETED:
12:20 PM
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Licensing Program Analyst Willis arrived unannounced to conduct a Case Management inspection and met with Licensee, Vilma Richardson.

LPA is following up regarding previous requests for facility's Closure Plan and resident eviction letters. LPA assisted Licensee with completion of these two items during this visit as they were not previously provided to CCL. LPA obtained additional information from Licensee including but not limited to the possibility of a Change of Ownership. The possibility of a Change of Ownership should be clarified by Monday, July 12, 2021. Licensee agrees to ensure residents and their responsible parties are kept up to date as the process continues. Additionally, Licensee will complete reappraisals for all residents by Thursday, July 15, 2021.

During this visit, LPA also obtained some documents that were requested for the current audit.

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: 07/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2021
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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