496803860-3-28-2023-21-AS-FSAI-CQCVVP-20230328164640

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803860
Report Date: 03/28/2023
Date Signed: 03/28/2023 04:46:59 PM

Document Has Been Signed on 03/28/2023 04:46 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:	ORTIZ, JUSTINE M.		FACILITY TYPE:	740
ADDRESS:	710 ROHNERT PARK EXPRESSWAY E		TELEPHONE:	(707) 710-7385
CITY:	ROHNERT PARK	STATE: CA	ZIP CODE:	94928
CAPACITY:	114	CENSUS: 84	DATE:	03/28/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Administration Staff, Janna O'Sullivan		TIME COMPLETED:	05:00 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 Analysts (LPAs), Farhaan Sarangi and Dina Alviso arrived unannounced at Clearwater at Sonoma Hills for the purpose of conducting a Required 1 year inspection. LPAs met with Administration Staff, Janna O'Sullivan, and was granted access into the facility. During the tour of the facility, LPA found a Medication Technician was not background cleared. (See LIC 809D, and See LIC 812-Background Clearance History for Medication Technician). Civil Penalty was also assessed. LPAs toured the facility with Administration Staff, Janna O'Sullivan. LPAs observed the facility to be clean and at a comfortable temperature with all exits free from obstruction. Perishable and Non-Perishable foods were observed in the kitchen fridge and freezer that was stored as per regulation. LPAs observed a large dining room that seat guests and residents. Water temperature on the second floor Assisted Living unit had a temperature of 117 degrees which is within Title 22 regulations. Water temperature on the first floor Memory Care Unit that had a temperature of 118 degrees in the faucet which is within Title 22 regulations, showers are equipped with Non-slip floors and handrails by shower and toilets for residents use. LPAs also observed the egress door in the Memory Care unit that is properly operational and functioning at this time. While touring, LPAs observed the Memory Care Unit dining room that was appropriate during the inspection. LPAs observed the outdoor seating area with tables and chairs along with two red corn hole decks outside of the Memory Care Unit. LPAs observed the locked Memory Care Unit Medication Room along with the locked Laundry room and Housekeeping room that keeps the hazardous toxins locked and inaccessible to residents in care. However, during the tour of the Assisted Living portion of the facility, both LPAs observed the cleaning supply cart to be unlocked and accessible to residents in care (See LIC 809D). All fire extinguishers were last serviced on November 18, 2022. First floor Bar is currently not servicing any residents at this time and the facility is working on hiring staff. LPAs observed the exercise room where residents can have access to those amenities. Exercise room is open and operating with staff supervision. LPAs observed a total of 2 evacuation chairs in 2 of 2 stairwells as required by Title 22 regulations. (Report continued on LIC 809C)

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2023

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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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: 03/28/2023

NARRATIVE

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Resident files were reviewed and residents were interviewed during the Required 1 year inspection. Staff files were reviewed. However, during the staff file review, 4 out of 5 staff files did not have a valid First Aid/CPR (See LIC 809D).

LPA requested the following documents to be sent:

LIC 500- Personnel Report
LIC 308- Designation of Responsibility
LIC 309- Administrative Organization
LIC 400- Affidavit regarding Client Cash Resources
Updated facility sketch
Updated Emergency Disaster Plan (LIC 610E)
Surety Bond
Most up-to-date Liability insurance
Control of Property
Register of residents
Fire Alarm System test

The following deficiencies were observed (See LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6, Chapter 8 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 and a copy of this report along with appeal rights were given to Facility Administration.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/28/2023 04:46 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: 03/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)(3)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 1 staff member was not associated to the facility. Furthermore, LPAs contacted the Santa Rosa Regional Office search the employee name and the employee was not found to be associated to Clearwater at Sonoma Hills. This poses an immediate health, safety or personal rights risk to residents in care.
	POC Due Date: 03/29/2023
	Plan of Correction
1 2 3 4	Plan of Correction shall include that the licensee associate employee to the facility and submit plan on future compliance with this regulation. POC due date March 29, 2023.

Type A

Section Cited

CCR

87411(c)(1)

Personnel Requirements - General

(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 4 out of 5 staff members did not have a current First Aid as required by Title 22 regulations. This poses an immediate health, safety or personal rights risk to persons in care
	POC Due Date: 03/29/2023
	Plan of Correction
1 2 3 4	Plan of Correction all 4 staff need to obtain First Aid training as required; Submit copies of all 4 first aid training certificates by due date April 5, 2023. Furthermore, Licensee shall submit a plan for future compliance with this regulation by March 29, 2023.

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 DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2023

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 03/28/2023 04:46 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: 03/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

87309 Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, LPAs observed 1 cleaning cart containing cleaners/toxins/disinfectants not being locked and staff was inside a Resident unit and away from the cart. This poses a Immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/29/2023
	Plan of Correction
1 2 3 4	Plan of Correction shall include staff training and the licensee to ensure that all toxins, disinfectants and cleaners are inaccessible to residents in care. Submit proof of in-service training on April 7, 2023 regarding the storage of toxins and cleaners. Furthermore, submit plan of correction and future compliance regarding this regulation by POC due date by March 29, 2023.

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: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2023

LIC809 (FAS) - (06/04)

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