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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803860
Report Date: 10/03/2024
Date Signed: 10/03/2024 05:31:23 PM


Document Has Been Signed on 10/03/2024 05:31 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:CLEARWATER AT SONOMA HILLSFACILITY NUMBER:
496803860
ADMINISTRATOR:MCCARRON, KATHLEENFACILITY TYPE:
740
ADDRESS:710 ROHNERT PARK EXPRESSWAY ETELEPHONE:
(707) 710-7385
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY:114CENSUS: DATE:
10/03/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:27 PM
MET WITH:James Homer-Executive DirectorTIME COMPLETED:
05:30 PM
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Licensing Program Analyst (LPA) Alviso conducted a case management inspection, on 10/3/2024 at approximately 1:27pm, and met with Executive Director, James Homer, and Health Services Director (HSD), LVN Janice Foster.

LPA reviewed resident incident with HSD Janice Foster. Per report and interviews, the administration staff reviewed facility video surveillance which showed staff (S4) grabbing a resident's (R1) hand aggressively to stop them from exiting. Resident had a fall during this incident, and was hospitalized. Staff (S4) was put on immediate suspension; and was terminated by administration staff due to the incident. The Department did receive an SOC341 suspected abuse report from the facility. Police report information case number obtained.

The LPA will obtain additional information regarding the above incident.

No deficiencies cited today.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2024
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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