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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804009
Report Date: 12/29/2021
Date Signed: 12/29/2021 10:19:28 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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:CLOVERDALE BETTER LIVING SENIOR CAREFACILITY NUMBER:
496804009
ADMINISTRATOR:GENET, MELISSAFACILITY TYPE:
740
ADDRESS:611 CHERRY CREEK ROADTELEPHONE:
(707) 367-2725
CITY:CLOVERDALESTATE: CAZIP CODE:
95425
CAPACITY:10CENSUS: 3DATE:
12/29/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Licensees, Melissa Genet and William LacayoTIME COMPLETED:
10:30 AM
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Licensing Program Analysts Victoria Willis and Caitlynn Felias arrived unannounced to conduct a Case Management Inspection and met with current and former Licensees Vilma Richardson, Melissa Genet and William Lacayo.

Facility received a provisional license effective 12/29/2021. Previous Licensee and live-in staff plans to be completely vacated from facility no later than 12/31/2021. LPAs and current Licensee discussed fingerprinting staff via the Guardian. Also discussed was the provisional license that is effective for one month. All physical plant issues must be remedied within that month. Licensee is in discussion with the landlord and has agreed to contact them via email notifying them that the facility is licensed and they must move forward in making repairs in order for the license to be permanently approved. Per discussion, the Licensee has contacted their insurance broker regarding their liability insurance. Once received, Licensee will submit proof of insurance to LPA.

Licensee and former Licensee understand that the former facility, Clearwater Lodge is closed as of 12/29/2021.

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

DATE: 12/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2021
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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