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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803860
Report Date: 10/27/2022
Date Signed: 10/27/2022 04:45:09 PM


Document Has Been Signed on 10/27/2022 04:45 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:LY, JENNIE MARIEFACILITY TYPE:
740
ADDRESS:710 ROHNERT PARK EXPRESWAY ETELEPHONE:
(707) 710-7385
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY:114CENSUS: DATE:
10/27/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Jennie Ly- Memory Care DirectorTIME COMPLETED:
04:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dina Alviso conducted a Case Management-Incident inspection and met with Memory Care Director Jennie Ly, and Health & Wellness Director Patricia Lundgren.

The inspection is being conducted to obtain more information, and review resident incident reports submitted by the facility to the Department. LPA reviewed seven (7) resident incident reports, and obtained more information as needed.

The LPA found that three(3) of the residents received medications in error from staff-staff didn't provide medications as ordered by the Physician. This deficiency will be cited, Incidental Medical and Dental Care 87465(C)(2)- see LIC8099D.

LPA found that an incident report of a meal provided to eight(8) memory care residents that had undercooked meat provided. Residents did consume the undercooked meat provided. Residents were monitored for any adverse reactions to eating the undercooked meat. This deficiency will be cited, 87555(b)(9)-see LIC809D.

The following deficiency will be cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with Health & Wellness Director,Patricia Lundgren..
Appeal Rights provided.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2022
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 10/27/2022 04:45 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: 10/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/28/2022
Section Cited

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Incidental Medical & Dental Care 87465(c)(2) 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:
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LPA reviewed incident report on resident medication errors, and interviewed staff- Three(3) residents received medications in error, medications were not provided as ordered by the Physician. This is a risk to residents Health & Safety. Civil Penalty assessed in the amount of $1000.
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Submit proof of training by 11/3/22. Submit plan of correction by 10/28/2022.
Type A
10/28/2022
Section Cited

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87555 (b)(9) General Food Service-Requirements
(b) The following food service requirements shall apply: (9)Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service.
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This requirement was not met as evidenced by: LPA reviewed incident report of meat that was undercooked being served to memory care residents. Residents did consume the food. This is a health and safety risk to residents in care.
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Retrain staff who cook and prepare food/meals regarding preparation and service to residents in care, ensuring safety practices at all times. Submit proof of training by 11/3/22. Submit plan of correction by 10/28/2022.
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: 10/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2022
LIC809 (FAS) - (06/04)
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