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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803894
Report Date: 05/04/2022
Date Signed: 05/04/2022 03:32:51 PM


Document Has Been Signed on 05/04/2022 03:32 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 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:
05/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Licensee, Melissa GenetTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Victoria Willis arrived unannounced to conduct an Annual Required inspection and met with Licensee, Melissa Genet. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival, LPA observed that facility has a table outside of the entrance to the facility with hand sanitizer and N95 Masks. Licensee screened LPA for Covid-19 symptoms. LPA confirmed with Licensee that visitors are screened and the facility is conducting vaccination verification per Provider Information Notice (PIN) 21-40-ASC. LPA conducted a walk-through of the facility with the Licensee and observed Covid-19 posters throughout the facility that included hand-washing signs in each bathroom. Per conversation with Licensee, they continue to check the temperature of residents and asks them screening questions. Staff are screened when they come on shift. Results are documented.

Facility has a designated visitation area outside and is allowing for visitation in resident rooms per CCL guidance. Staff have completed PPE training and have been N95 fit tested. LPA and Licensee discussed visitation and activities.

Facility has submitted and CCL has reviewed their Covid Mitigation Plan. Facility has more than a 30 day supply of Personal Protective Equipment (PPE) including but not limited to masks, gowns, and hand sanitizer. Facility maintains a 30 day supply of medication. Fire extinguishers were last serviced October 2021.

Continued on LIC809C

SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria WillisTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2022
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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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 RESIDENTIAL CARE
FACILITY NUMBER: 496803894
VISIT DATE: 05/04/2022
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Continued from LIC809

Licensee and LPA discussed their Emergency Disaster Plan and the Infection Control Plan that is due to CCL no later than June 30, 2022.



Licensee/Administrator to submit updates of the following documents by: 6/4/2022
LIC 308 Designated Administrator
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Resident’s
Copy of current Lease/Rental Agreement showing you have control of property.


No deficiencies cited during this inspection.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria WillisTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022
LIC809 (FAS) - (06/04)
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