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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803631
Report Date: 07/28/2021
Date Signed: 07/28/2021 11:12:25 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
07/23/2021 and conducted by Evaluator Victoria Willis
COMPLAINT CONTROL NUMBER: 21-AS-20210723151725
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
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Licensee, Vilma RichardsonTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Facility failed to issue refund
INVESTIGATION FINDINGS:
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Licensing Program Analyst Willis arrived unannounced to conduct a complaint investigation regarding the above complaint allegation and met with Licensee, Vilma Richarson.

Complaint alleges that a resident's responsible party was not refunded following resident's passing. Conversation with Licensee confirmed that a resident who passed June 26, 2021 has not yet been reimbursed per regulation.

The allegation that facility failed to issue refund 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.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.
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: 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.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 21-AS-20210723151725
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: 07/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/12/2021
Section Cited
HSC
1569.652(c)
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§1569.652 Termination of admission agreement upon death of resident; removal of resident’s property; refund of fees paid; notice of contract termination and refunds. (c) A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual, individuals, or entity
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Licensee to provide proof that resident's responsible party has been reimbursed per regulation by POC due date, August 12, 2021.
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contractually responsible for the fees or, if the deceased resident paid the fees, to the resident’s estate, within 15 days after the personal property is removed. Licensee did not meet this requirement based on: Interview with Licensee confirmed that they have not refunded the responsible party for a resident who passed away 6/26/21.
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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: 07/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2