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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803860
Report Date: 06/25/2025
Date Signed: 06/25/2025 12:33:17 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/02/2025 and conducted by Evaluator Dina Alviso
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20250602102129
FACILITY NAME:CLEARWATER AT SONOMA HILLSFACILITY NUMBER:
496803860
ADMINISTRATOR:HOMER, JAMESFACILITY TYPE:
740
ADDRESS:710 ROHNERT PARK EXPRESSWAY ETELEPHONE:
(707) 710-7385
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY:114CENSUS: DATE:
06/25/2025
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:James Homer-AdministratorTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff are mismanaging resident's medication and not providing it to the resident as prescribed
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 6/25/25 at approximately 9:40am, and met with Administrator/Executive Director James Homer and Health Services Director Eadgitha Waken.

Reporting party alleges "staff are mismanaging resident's medication and not providing it to the resident as prescribed". LPA reviewed resident's (R1) records, medication records, care plan, assessments, and financial records on care plan fees. LPA obtained copies of resident (R1) records as requested. LPA obtained a copy of notice of fees regarding care plan levels, and medication assistance costs, letter dated 3/31/25. The 3/31/25 letter of new fee structure for assisted living and memory support was mailed out to all resident responsible parties, per Administrator. LPA interviewed staff, S1, and S2, and other related parties.

The investigation revealed that R1's medication prescribed for mood and anxiety had been changed by the Physician, dosage was changed to three pills a day to be given at dinner time, approximately 4/9/25. R1 received their last dose of the medication on 4/19/25, per medication MAR review.

Continued on LIC9099C..
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 21-AS-20250602102129
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: CLEARWATER AT SONOMA HILLS
FACILITY NUMBER: 496803860
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/25/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/26/2025
Section Cited
CCR
87465(a)(4)
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87465(a)(4) Incidental Medical and Dental Care-The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Per review of records, R1 received last dose of the medication 4/19/25. The medication assistant staff didn't refill the medication as required. Resident R1 was not provided the medication as prescribed from 4/20/25 through 5/24/25, per medication MAR review.
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CORRECTED/POC CLEARED.
BY HEALTH SERVICES DIRECTOR HELD AN IN-SERVICE MEDICATION TRAINING WITH ALL MEDICATION ASSISTANCE STAFF. ADMINISTRATION STAFF INSTITUTED A WEEKLY AUDIT TO HELP
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The medication was refilled/obtained, and resident was provided the medication as ordered on 5/25/25; R1 missed a total of "35" days of the prescribed medication, per review of records and conducted interviews. This is a health & safety risk to the resident (s) in care.
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ENSURE ALL MEDICATIONS ARE REFILLED AS REQUIRED, AND ALL MEDICATIONS ARE PROVIDED AS PRESCRIBED TO RESIDENTS IN CARE.
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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.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 21-AS-20250602102129
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: CLEARWATER AT SONOMA HILLS
FACILITY NUMBER: 496803860
VISIT DATE: 06/25/2025
NARRATIVE
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Continued from LIC9099, dated 6/25/25..

The medication assistant staff didn't refill the medication as required. Resident R1 was not provided the medication as prescribed from 4/20/25 through 5/24/25, per medication MAR review. The medication was refilled/obtained, and resident was provided the medication as ordered on 5/25/25; R1 missed a total of "35" days of the prescribed medication order, per review of records and conducted interviews. Sufficient information has been obtained to support that a violation had occurred.

Per review of records, including medication records, facility records, and interviews with staff and other parties, the allegation "staff are mismanaging resident's medication and not providing it to the resident as prescribed" is substantiated. This deficiency will be cited, 87465(a)(4) Incidental Medical and Dental Care, see LIC9099D.

The preponderance of evidence standard has been met, therefore the allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited.

Failure to correct deficiencies by due dates, may result in additional deficiency citations and/or civil penalties being assessed.
Exit interview conducted with the Administrator James Homer.
Appeal Rights provided to the Administrator.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3