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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803672
Report Date: 12/20/2022
Date Signed: 12/20/2022 03:17:49 PM


Document Has Been Signed on 12/20/2022 03:17 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



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:
12/20/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:43 PM
MET WITH:Ami Kumar (Licensee)TIME COMPLETED:
03:32 PM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a Case Management Inspection and met with Licensee, Ami Kumar.

LPA is following up on a recently self-report incident at the facility, which resulted in a suspected physical abuse report. SIR Report was submitted to CCL on 12/20/2022 along with SOC 341. On 12/16/22 Resident (R1) who recently moved into the facility. Upon arrival resident started to refuse medication, food, screaming out and swinging at staff when they try to provide incontinence care. Licensee notified their Physician about their behaviors and were advised to give resident a couple more days for adjustment and they will put a referral for hospice services. On 12/19/22 Kaiser sent a therapist to evaluate resident and was told by resident that staff are hitting them. Per incident report, on 12/20/22 R1 punched a staff (S1) in their face. Per Licensee, after the incident they had a talk and was told by R1 that they wanted to go back home and Licensee advised R1 to get stronger so they can return home sooner which R1 agreed.

During today's visit, LPA observed R1's fiduciary and Ombudsman were present interviewing R1. LPA also conducted interviews with them, staff and R1. Based on observations, interviews and records review, R1's care plan dated 12/12/22 and Physician's report dated 11/30/22 R1 does not have a diagnosis of dementia, but their mental condition experiences some intermittent confusion. LPA spoke with R1 who did not specify any information nor staff involved with this alleged abuse. Facility investigated incident, but there were no physical signs of abuse observed, responsible parties were notified. Facility conducted a physical assessment to R1 who is always assisted with ADLs and transfers. Based on interviews conducted by Licensee with staff, the allegations are not substantiated. The Department will be reviewing the information obtained to determine if further actions are needed.

No deficiencies cited during today's visit.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2022
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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