<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803860
Report Date: 10/01/2021
Date Signed: 10/01/2021 05:01:17 PM

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:CLEARWATER AT SONOMA HILLSFACILITY NUMBER:
496803860
ADMINISTRATOR:WHITACRE, DERRICKFACILITY TYPE:
740
ADDRESS:710 ROHNERT PARK EXPRESWAY ETELEPHONE:
(707) 710-7385
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY:114CENSUS: DATE:
10/01/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:52 PM
MET WITH:Derrick Whitacre-AdministratorTIME COMPLETED:
05:10 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Dina Alviso conducted a Case Management-Incident inspection and met with Derrick Whitacre, Administrator; The inspection is being conducted to obtain more information and review some incident reports submitted as required to the Department.

LPA reviewed seven (7) resident incident reports, and obtained more information as needed. The LPA found that 5 of the residents had medication errors of staff not providing the medication to the residents as ordered: The individual dates of the residents, R1, R2, R3, R4, and R5, not having been given their medications as required and prescribed, happened in and between the months of March 2021 through September 2021. Most of these medication errors had been followed up with medication training provided to all staff handling medication assistance to the residents in care. The trainings, Medication Assistance Procedures By Med Techs, were in-serviced on 7/4/2021, 7/10/2021, 7/19-7/22, 2021, and 10/1/2021.

Resident incidents, two (2) , Medication errors by staff not providing medications as prescribed on 8/4/21 and 9/25/21, will also need follow-up medication training by the Nurse of the facility. The deficiency for all medication errors will be cited today, regulation 87465 Incidental Medical and Dental Care, see LIC809D.

The following deficiency will be cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with Administrator Derrick Whitacre. Appeal Rights Given.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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: CLEARWATER AT SONOMA HILLS
FACILITY NUMBER: 496803860
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/04/2021
Section Cited

1
2
3
4
5
6
7
Incidental Medical and Dental Care 87465(a)(5)The licensee shall assist residents with self-administered medications as needed. This requirement has not been met as evidence by:
8
9
10
11
12
13
14
LPA's observations, review of records, and interviews with Administrator and Health Services Director regarding the incident reports submitted on medication errors by staff assisting residents, (R1through R5, with prescribed medications and failing to ensure medications are given as prescribed. This ia an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
and what the topics covered will be, and who will be the Trainer. This is due by 10/4/2021. Submit no later than 10/18/21, with completed medication trainings, with above information, including date/time/attendees as proof of needed and current training.

1
2
3
4
5
6
7

1
2
3
4
5
6
7
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: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 10/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/01/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2