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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803672
Report Date: 10/17/2024
Date Signed: 10/17/2024 03:39:15 PM


Document Has Been Signed on 10/17/2024 03:39 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:
10/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Ami Kumar (Licensee)TIME COMPLETED:
03:54 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required inspection and met with Janine Sorensen, back up Administrator. Licensee Ami Kumar arrived later.

LPA/staff initiated a tour of the facility at 2:05 pm and observed the following: Facility was a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Bathrooms have required mats and grab bars. Water in resident bathrooms measured at 108.4 F, 115.2 F and 112.2 F which are within the range allowable by regulation. Extra linens and hygiene products were available. Toxins are stored in a locked cabinet under the kitchen sink and locked cabinet in the laundry room. Medications are centrally stored and locked in a kitchen cabinet. Facility has at least two days of perishable and one week of nonperishable foods of good quality. Fire extinguishers were all charged and 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 7/15/2024. Required postings were observed.

File review was initiated at 2:30 pm. Three staff and six resident files were reviewed. Residents have current medical assessments and care plans. All staff have required additional 20 training hours and 1st aid/CPR Certificates current. Administrator Certificate for Ami Kumar, 7006603740, expires 11/8/2024. Medication and medication records were reviewed. Annual fees are current. Contact information was reviewed.

The facility agrees to submit updates of the following documents by 10/31/24: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500), copy of liability insurance certificate.

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 copy of this report was provided.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2024
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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Document Has Been Signed on 10/17/2024 03:39 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's/Licensee observation, the Licensee did not comply with the section cited above in 2 out of 2 fire extinguisher was not serviced since April 2023, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/31/2024
Plan of Correction
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Licensee will contact the Fire Department to have fire extinguisher serviced. Licensee agreed to submit self-certification form as a proof of Correction (POC) that fire extinguishers have been serviced and charged by a fire extinguisher service company or the Fire Department by POC due date 10/31/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2024
LIC809 (FAS) - (06/04)
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