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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803894
Report Date: 11/24/2020
Date Signed: 11/24/2020 04:25:03 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/19/2020 and conducted by Evaluator Victoria Willis
COMPLAINT CONTROL NUMBER: 21-AS-20201119092004
FACILITY NAME:CLEARWATER RESIDENTIAL CAREFACILITY NUMBER:
496803894
ADMINISTRATOR:GENET, MELISSAFACILITY TYPE:
740
ADDRESS:627 CHERRY CREEK ROADTELEPHONE:
(707) 892-3362
CITY:CLOVERDALESTATE: CAZIP CODE:
95425
CAPACITY:8CENSUS: 6DATE:
11/24/2020
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Licensee, Melissa GenetTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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Faciltiy staff failing to wear masks/face coverings
INVESTIGATION FINDINGS:
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LPA Willis conducted a Televisit with Licensee, Melissa Genet due to Covid-19 precautions.

LPA received information that a a staff was not wearing a mask while in the facility and when asked to put it on, seemed confused by the request and delayed putting on the mask. Interview with Licensee confirmed that staff was not wearing a mask and expressed the difficulty of providing care to residents with dementia while wearing a mask but understands that masks must be worn. On November 13, 2020, licensee failed to protect the personal rights of clients in care to receive safe and healthful accommodations and engaged in conduct inimical to the health, welfare, and safety of clients in care, in that staff failed to wear face coverings while providing care and supervision to clients in care, in violation of official government orders requiring the wearing of face coverings while working under specified conditions.

The allegation that faciltiy staff is failing to wear masks/face coverings is Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria WillisTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:

DATE: 11/24/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/24/2020
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 2
Control Number 21-AS-20201119092004
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: CLEARWATER RESIDENTIAL CARE
FACILITY NUMBER: 496803894
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/24/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/25/2020
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(2) To be accorded safe, healthful & comfortable accommodations, furnishings and equipment. This requirement hasn't been met based on interviews indicating that on 11/13/2020 licensee failed to protect
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Licensee agrees to sigh up for infection control training provided through the Long Term Care Ombudsman Office and will submit proof of training to CCL by POC due date, 11/25/2020.
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personal rights of clients in care to receive safe & healthful accommodations in that staff failed to wear face coverings while providing care & supervision to clients in care, in violation of official government orders requiring the wearing of face coverings while working under specified conditions. This is an immediate risk to health & safety of residents.
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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: Victoria WillisTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:

DATE: 11/24/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/24/2020
LIC9099 (FAS) - (06/04)
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