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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803894
Report Date: 07/15/2022
Date Signed: 07/15/2022 09:20:44 AM


Document Has Been Signed on 07/15/2022 09:20 AM - 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: 0DATE:
07/15/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Licensee, Melissa GenetTIME COMPLETED:
09:30 AM
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Licensing Program Analyst Willis met with Licensee, Melissa Genet to conduct a final walk through of the facility.

Licensee notified LPA on May 4, 2022 that they were seeking another home to do a Change of Location but if they were unable to find a suitable place, they would be closing and all residents and their responsible parties were notified. On July 6. 2022, Licensee notified LPA that they would not be doing a Change of Location and have vacated the home. All residents have moved to the Licensee's other facility on the property. At approximately 8:50am LPA conducted a walk through and observed the following: The majority of furniture including beds have been removed from the facility. There are no personal belongings in rooms or linens on beds. The refrigerator has been removed.

LPA obtained the facility license during inspection and will continue with the closure process.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria WillisTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:
DATE: 07/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/15/2022
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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