496803860-3-23-2022-21-AS-DALO-CCSVKK-20220323163029

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803860
Report Date: 03/23/2022
Date Signed: 03/23/2022 04:30:39 PM

Document Has Been Signed on 03/23/2022 04:30 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 HILLS		FACILITY NUMBER:	496803860
ADMINISTRATOR:	WHITACRE, DERRICK		FACILITY TYPE:	740
ADDRESS:	710 ROHNERT PARK EXPRESWAY E		TELEPHONE:	(707) 710-7385
CITY:	ROHNERT PARK	STATE: CA	ZIP CODE:	94928
CAPACITY:	114	CENSUS: 85	DATE:	03/23/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:35 PM
MET WITH:	Derrick Whitacre-Administrator		TIME COMPLETED:	04:35 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 1 year required inspection and met with Administrator Derrick Whitacre. The inspection is focused on the Infection control procedures and practices of this facility. Currently eighty-five (85) residents in care, twenty-three (23) of the residents are in memory care unit. Hospice care waiver approved for ten(10) residents. Mitigation plan submitted and reviewed by the Department. Fire clearance approval is for 114 non-ambulatory residents, which includes 6 bedridden. Facility does have an approved dementia plan. The LPA toured the facility with the Administrator. Facility has sanitizer available in the entry area, and this is where all staff and visitors are screened, and temperatures taken. All screenings are logged. Facility was found to be clean, orderly, and at a comfortable temperature. LPA observed exits free from obstruction. Sufficient supply of hygiene products, cleaners, and paper products for use as needed. Sufficient food supply. All postings were up and visible to all as required. Facility has a sufficient supply of personal protective equipment(PPE) within the facility for use as needed. Residents have masks available to them for their use if needed and/or wanted. Administrator stated that all staff wear masks in the facility, including when providing care services to the residents in and out of the facility. Administrator had a mask on during the LPA's inspection, and all the staff the LPA observed during the inspection had a mask on. LPA observed the stairwell(s), and the evacuation chair(s) were in place, including the instructions on their use in an emergency. The LPA observed the fire extinguishers were serviced on November, 21/2021-they are serviced and tagged as required. The local fire Department was out approximately a month ago and checked the fire alarm system-all was approved. Continued on LI809C...

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022

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 03/23/2022 04:30 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: 03/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(c)(2)

Incidental Medical and Dental Care Services

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	LPA's review of resident incidents, R1 12/5, R2 11/20, R3 3/20/22, R4 11/20, & R5 10/12 & 10/13, residents had not received their medication as prescribed by the Physician. Based on LPA's record reviews on resident incident reports, the licensee did not comply with the section cited above in [5] out of [5] resident assistance with prescribed medications which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/24/2022
	Plan of Correction
1 2 3 4	Licensee to ensure that all staff that handle medications, and assist residents with their medications, are in-serviced regarding medication assistance, and also ordering medication refills in a timely manner for residents in care. The plan of correction is due no later than 3/24/22. Provide proof of training as listed above, include Trainer-Topics- Date/Time spen-Attendees-due 1/30/22.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022

LIC809 (FAS) - (06/04)

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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
	VISIT DATE: 03/23/2022

NARRATIVE

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Per LPA's review of resident incidents, R1 12/5, R2 11/20, R3 3/20/22, R4 11/20, & R5 10/12 & 10/13, residents had not received their medication as prescribed by the Physician. This deficiency will be cited, Incidental Medical and Dental Services, Regulation 87465(c)(2).

California Code of Regulations, (Title 22, Division 6, Chapter 8) and/or Health & Safety Code, is being cited on the following 809D page. Failure to correct deficiencies by plan of correction due date(s) may result in civil penalties.

Exit interview conducted.

Appeal Rights given to the Administrator Derrick Whitacre.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022

LIC809 (FAS) - (06/04)

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