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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803860
Report Date: 04/17/2024
Date Signed: 04/17/2024 06:09:40 PM


Document Has Been Signed on 04/17/2024 06:09 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:CLEARWATER AT SONOMA HILLSFACILITY NUMBER:
496803860
ADMINISTRATOR:O'SULLIVAN, JANNAFACILITY TYPE:
740
ADDRESS:710 ROHNERT PARK EXPRESSWAY ETELEPHONE:
(707) 710-7385
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY:114CENSUS: 89DATE:
04/17/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:20 PM
MET WITH:Janna O'Sullivan-AdministratorTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs), Alviso and Florio, conducted a case management-other inspection, on 4/17/24 at approximately 4:27 pm, and met with Administrator Janna O'Sullivan, and Health Services Director Janice Foster.

This inspection is being conducted to cite a deficiency that was identified during the complaint inspection of earlier today, see LIC9099, dated 4/17/24.

There were some concerns regarding the resident's hygiene care, and updating the plan to ensure needs will/can be met. A meeting was held to discuss concerns, Per LPA interviews with staff, It was identified that staff, S2, made an inappropriate comment during the meeting held to address a resident's (R1) care plan; In summary, the comment regarded the hygiene care plan, previously this type of plan was referred to as the "grandma and grandpa stinky club." This deficiency will be cited, 87468.1(a)(1) Personal Rights of Residents in All Facilities- Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded dignity in their personal relationships with staff, residents, and other persons, see LIC809D.

The following deficiency was cited from the California Code of Regulations, Title 22, Division 6, Chapter 8 of California Regulation and/or Health & Safety Code. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.
Exit interview conducted with the Administrator.
Appeal rights provided.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 04/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2024
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 04/17/2024 06:09 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: CLEARWATER AT SONOMA HILLS
FACILITY NUMBER: 496803860

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/03/2024
Section Cited
CCR
87468.1(a)(1)

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87468.1(a)(1) Personal Rights of Residents in All Facilities- Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by: LPA interviews identified that staff, S2, made an inappropriate comment during the meeting

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Licensee/Administrator to ensure that no residents personal rights are violated, per regulation. Contact Sonoma County Ombudsman Agency and schedule a "Resident Personal Rights" training for care staff, including S2.
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held to address a resident's (R1) care plan; In summary, the comment regarded the hygiene care plan, previously this type of plan was referred to as the "grandma and grandpa stinky club." This is a potential risk to residents' personal rights and/or risk to health and safety.
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Once the training is obtained from the Ombudsman Agency for facility staff, submit proof of training, and plan of facility future compliance with this regulation.
POC due by 5/3/24.

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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: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 04/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2024
LIC809 (FAS) - (06/04)
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