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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803672
Report Date: 08/08/2023
Date Signed: 08/08/2023 12:12:57 PM

Document Has Been Signed on 08/08/2023 12:12 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:
08/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:32 AM
MET WITH:Ami Kumar (Licensee)TIME COMPLETED:
12:27 PM
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Licensing Program Analysts (LPAs) Christi Coppo and Marisol Cuadra arrived unannounced to conduct an Annual required inspection and was greeted by individual (I1). Licensee Ami Kumar arrived later. LPAs observed I1 was providing care to residents at the facility at the time of visit. LPA informed Licensee that I1 is not associated to facility and should never be working and providing care to residents prior to a criminal record clearance or exemption. ***Civil penalties are being assessed in the amount of $100 per day for allowing a person to work, reside or volunteer in the facility without a fingerprint clearance/transfer per two weeks for a total of $500.

LPAs/staff initiated a tour of the facility around 9:00am and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Residents rooms were furnished per regulation. Extra hygiene products and linens were available. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation. Two fire extinguisher was last serviced April 2023. Smoke alarms are hard wired with sprinklers and fire doors on each resident room as well as a fire door in the hallway. Smoke alarms and carbon monoxide detector was tested and operational at time of inspection. Last Disaster drill was conducted on 7/10/23. Working auditory alarms are placed on all exits. Disinfectants and cleaning solutions were stored inaccessible to residents. Required postings were observed. Administrator Certificate for Ami Kumar, 6021684740, expires on 11/8/24. Medications were centrally stored and locked. Hot water temperature reading was 113.2 and 110.4 degrees which is within regulation.

Continues on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 08/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 CARE
FACILITY NUMBER: 496803672
VISIT DATE: 08/08/2023
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Continued from LIC809...

LPA initiated file review at 9:30 am. LPA reviewed six residents files and five staff files. All residents files have a current medical assessment and care plans updated within the last 12 months. Staff records have current First Aid/CPR certificates and additional 20 hours of required training.

At approximate 11:00am LPA/staff conducted a spot check of medication and found resident's (R1 & R2) medications were not current into the Centrally Stored Medication. Licensee agreed to review and update the Centrally Stored Medication Records.

Licensee agreed to submit updates of the following documents by 8/22/23: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500) and Copy of Liability Insurance.

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.

Exit interview was conducted with Licensee and a copy of this report was provided.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/08/2023 12:12 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 08/08/2023 at 11:54 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: CLOVER SENIOR CARE
FACILITY NUMBER: 496803672

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, record review and interview with Licensee did not ensure to obtain a criminal record clearance for staff (S1) prior to work, reside or provide care to residents in care which poses an immediate health, safety and personal rights risk to residents in care. ***Civil Penalty is being assesed for the amount of $500.
POC Due Date: 08/09/2023
Plan of Correction
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Licensee removed staff (S1) from the premises and from the work schedule until S1 has a clearance as required by law. Licensee will submit a self-certification LIC9098 ensuring that regulation was understood to CCL by POC due date.
Type A
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not maintaining a Centrally Stored Medication Log which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/09/2023
Plan of Correction
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Facility to review and update the Centrally Stored Medication Log by POC due date. Licensee will submit self-certification LIC9098 notifying CCL that CSMR its current. LPA will return to review.
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:Bethany Moellers
LICENSING EVALUATOR NAME:Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2023


LIC809 (FAS) - (06/04)
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