<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803631
Report Date: 07/28/2021
Date Signed: 07/28/2021 11:15:18 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: 5DATE:
07/28/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Licensee, Vilma RichardsonTIME COMPLETED:
11:30 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst Willis arrived unannounced to conduct a Case Management inspection and met with License, Vilma Richardson.

LPA is following up regarding facility's closure. Facility has notified all residents and their responsibility parties of the closure date of September 8, 2021. The licensee has indicated that there is a potential for a change of ownership but that has not been finalized and an application has not been received by the department.

Since the announcement of the closure, one resident has moved and another has passed away. Per conversation with Licensee, one resident who is related to the Licensee may be moving however, the remaining four residents do not have current plans to move and are instead anticipating a change of ownership where they may remain in the home.

LPA is also following up regarding a resident who passed away but was not on hospice. According to conversation with Licensee, resident was having breathing issues following a stay in the hospital. After returning to the facility, resident was assessed by a home health nurse who suggested that resident go back to the hospital. Resident passed at the hospital.

LPA also discussed the facility's Mitigation Plan and LPA followed up on the request for the facility's LIC808. LPA reminded Licensee that the LIC808 is needed no later than Friday, 7/30/2021.

No deficiencies cited.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria WillisTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1