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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803672
Report Date: 08/31/2023
Date Signed: 08/31/2023 02:33:42 PM


Document Has Been Signed on 08/31/2023 02:33 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:
08/31/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:21 PM
MET WITH:Janine Sorensen (back up Administrator)TIME COMPLETED:
02:48 PM
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Licensing Program Analysts (LPAs) Cuadra and Coppo arrived unannounced for the purpose of conducting a plan of correction visit and met with back up Administrator Janine Sorensen.

LPA is following up regarding deficiencies cited during the August 8, 2023 Annual Required inspection.
The following deficiencies have been corrected:
87465(h)(6) - Centrally Stored Medication Log is maintained.

During today's visit, LPAs reviewed records including medication for residents in care. The facility has corrected previous deficiencies and items of concern appeared to be in compliance with Title 22 regulations.

No deficiencies cited during today's inspection.

Exit interview conducted with Administrator and a copy of this report was given.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2023
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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