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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803860
Report Date: 09/02/2022
Date Signed: 09/02/2022 04:57:37 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
05/23/2022 and conducted by Evaluator Dina Alviso
COMPLAINT CONTROL NUMBER: 21-AS-20220523102625
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: 96DATE:
09/02/2022
UNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Derrick Whitacre-AdministratorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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9
Resident wandered away from the facility
INVESTIGATION FINDINGS:
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Licensing Program Analyst(LPA) Alviso, conducted a complaint inspection, on 9/2/22 at approximately 9:35am, and met with Administrator Derrick Whitacre, and Health Services Director Patricia Lundgren.
This is a subsequent inspection; LPA interviewed staff, and other interested parties regarding the allegations. LPA requested and received copies of documentation from resident files, and staff files. LPA toured the facility each time when conducting the inspections. Resident (R1) incident reports were reviewed by the LPA.The investigation revealed that resident (R1) did wander away from the faciity without staff supervision as required. Based on LPA interviews, and review of information obtained, the investigation has revealed that the allegation of "resident wandered away from the facility" has been substantiated.
Though the allegation is substantiated there will be no citation issued today because the resident incident of wandering was cited in a case management inspection conducted on 6/2/2022. The citation has been corrected and cleared by the facility as required by the plan of correction. See licensing report LIC809/809D dated 6/2/2022.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2022
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
05/23/2022 and conducted by Evaluator Dina Alviso
COMPLAINT CONTROL NUMBER: 21-AS-20220523102625

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:
09/02/2022
UNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Derrick Whitacre-AdministratorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Multiple residents fell and sustained injuries due to lack of supervision
Residents are being left unattended in soiled diapers for extended periods
Resident was handled in a rough manner
Resident(s) are not treated with respect and dignity
Facility is unkempt
Staff are not qualified to meet the needs of residents

INVESTIGATION FINDINGS:
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13
Licensing Program Analyst(LPA) Alviso, conducted a complaint inspection, on 9/2/22 at approximately 9:35am, and met with Administrator Derrick Whitacre, and Health Services Director Patricia Lundgren.
This is a subsequent inspection; LPA interviewed staff, and other interested parties regarding the allegations. LPA requested and received copies of documentation from resident files, and staff files. LPA toured the facility each time when conducting the inspections. Resident incident reports were reviewed by the LPA. Nine (9)Staff training records were reviewed, and interviews were conducted. The investigation revealed that residents that had falls were not identified as needing one to one staffing, and all the residents are on fall risk care plans. Resident falls reviewed were identified to have been addressed per facility policies and care plans.
continued on LIC9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 21-AS-20220523102625
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/02/2022
NARRATIVE
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Staff interviewed stated that they assist residents as needed for incontinent care needs, and they check on resident three times per shift, and some residents have checks once every hour and/or every two hour, based on residents individual needs. The staff state they communicate any resident information from their shift to the staff coming on before they leave their shift. All staff stated the residents incontinent needs are met as required, and no residents are left in soiled diapers, and if someone needs changing at end of shift the staff notifies shift coming on. Staff stated that they have not handled any resident roughly and/or observed any other staff person handle a resident roughly. Staff stated that they have not verbally and/or physically abused a resident in any way and have not observed a staff person abuse any resident. Per record reviews, all staff had required training. Per interviews, staff were knowledgeable in procedures and policies of the facility in regards to providing resident care, including incontinent care. LPA toured the facility during inspections, LPA observed the memory care unit to be clean and orderly.

Based on LPAs observations, record reviews, interviews with staff, and information obtained from other related party(s) there is insufficient information to prove or disprove the allegation of " multiple residents fell and sustained injuries due to lack of supervision, residents are being left unattended in soiled diapers for extended periods, resident was handled in a rough manner, resident(s) are not treated with respect and dignity, facility is unkempt, staff are not qualified to meet the needs of residents" Although the allegation(s) may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation(s) is Unsubstantiated.
No deficiencies cited.
Exit interview conducted with Administrator Derrick Whitacre.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
05/23/2022 and conducted by Evaluator Dina Alviso
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20220523102625

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:
09/02/2022
UNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Derrick Whitacre-AdministratorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Incidents are not being reported as required
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst(LPA) Alviso, conducted a complaint inspection, on 9/2/22 at approximately 9:35am, and met with Administrator Derrick Whitacre, and Health Services Director Patricia Lundgren.
This is a subsequent inspection; LPA interviewed staff, and other interested parties regarding the allegations. LPA requested and received copies of documentation from resident files, and staff files. LPA toured the facility each time when conducting the inspections. Facility resident incident reports were reviewed by the LPA.The investigation revealed that the facility Administration staff is submitting incident reports as required.
Based on the interviews, record/document reviews, information obtained during the investigation, the allegation"incidents are not being reported as required" are UFOUNDED. We have found that the complaint allegation was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.
No deficiency cited.
Exit interview was conducted with the Administrator.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4