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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803631
Report Date: 08/13/2021
Date Signed: 08/13/2021 01:18:10 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: 4DATE:
08/13/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
12:28 PM
MET WITH:Licensee, Vilma RichardsonTIME COMPLETED:
01:30 PM
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Licensing Program Analyst Willis arrived unannounced to conduct a Plan of Correction visit and met with Licensee, Vilma Richardson.

LPA issued a violation of Health and Safety Code ยง1569.652 for the facility on 7/28/2021 with a correction date of 8/12/2021. Based on conversation with Licensee during this visit, they have not refunded money due following the death of a resident, therefore the deficiency has not been corrected.

Civil penalties are being assessed today in the amount of $100.00 for failure to correct deficiency and will continue to run at $100.00 per day until corrected.

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

DATE: 08/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2021
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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