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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803672
Report Date: 07/21/2021
Date Signed: 07/21/2021 11:35:24 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:CLOVER SENIOR CAREFACILITY NUMBER:
496803672
ADMINISTRATOR:KUMAR, AMIFACILITY TYPE:
740
ADDRESS:1171 CLOVER DRIVETELEPHONE:
(707) 304-4790
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY:6CENSUS: 6DATE:
07/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Ami Kumar, LicenseeTIME COMPLETED:
11:45 AM
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Licensing Program Analysts (LPAs) Lopez and Cuadra conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility. LPAs were greeted by staff and then Licensee, Ami Kumar arrived later. LPAs conducted a Risk Assessment call with Licensee prior to the visit. There were 6 residents in care present at the facility. 3 residents were on hospice and 3 residents were not.

LPAs arrived at the facility and had their temperature checked and logged into a sign-in sheet. LPAs continued tour of the facility on July 21, 2021. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on April 14, 2021 at the time of the visit. Facility smoke detectors and carbon monoxide were found to be functioning properly at the time of the visit. There was sufficient amount of supply for both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. There was a supply of cleaners, hygiene products and paper products available for residents. The bathroom designated for residents at the facility were supplied with individual paper towels; hand soap dispenser was available.

Facility has submitted a mitigation program plan that has been approved 3/29/21. Per licensee, all staff have been vaccinated. Posters have been placed at entrance, and facility entrance area has a designated area to screen visitors, thermometer and other items designated for visitors and staff before coming into work. Staff and residents are being monitored daily and results are documented in a binder for each month. Facility has PPE supplies stored in the storage room. Facility has a 30-day supply of medication for residents. Residents do not typically wear masks inside the facility but have them available. Facility has conducted staff training on infection control.

No deficiencies observed or cited during today's Required 1- Year inspection.

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Karen LopezTELEPHONE: (707) 588-5048
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2021
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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