<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804009
Report Date: 03/02/2022
Date Signed: 03/02/2022 12:57:12 PM


Document Has Been Signed on 03/02/2022 12:57 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: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: 2DATE:
03/02/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Licensee, Melissa GenetTIME COMPLETED:
01:06 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 Analyst Willis arrived unannounced to conduct a Post Licensing Inspection. and met with Licensee, Melissa Genet. The inspection is focused on the Infection Control procedures and practices of this facility but LPA made additional observations.

Upon arrival, Licensee checked LPA's temperature and documented in the visitor log. Facility has visitors sign in and asks them standard Covid-19 screening questions. Facility also conducts vaccination verification of visitors per CCL guidance. LPA conducted a walk-through of the facility and observed the following: Facility has COVID-19 posters throughout the facility that includes hand-washing signs located in bathrooms. Facility was a comfortable temperature and exits were free from obstruction. Previous physical plant issues have been corrected including replacement of a window in a resident room, replacing vanities in seven resident rooms, fixing the HVAC system, replacing and painting deck boards and filling in gaps on concrete sidewalk. Additionally, the Licensee has turned a previous area used as an office and storage area into a common area for residents that includes tables for activities. Facility has been painted in the interior and all rooms are set up per regulation. Hand sanitizer was available in common areas. LPAs observed staff wearing masks during this visit. Commonly touched surfaces are disinfected at least once per day. Staff are screened prior to each shift and residents are screened daily.

LPAs and Licensee discussed resident activities and visitation.

LPA confirmed that Licensee has created new Admission Agreements and Assessments due to retaining residents from the previous facility at this location.

Continued on LIC809
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria WillisTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:
DATE: 03/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


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: CLOVERDALE BETTER LIVING SENIOR CARE
FACILITY NUMBER: 496804009
VISIT DATE: 03/02/2022
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
26
27
28
29
30
31
32
Continued from LIC809

Facility has at least a 30 day supply of Personal Protective Equipment (PPE) including surgical masks, gloves, gowns, and hand sanitizer. Staff have been N-95 fit tested and trained regarding proper use of PPE.

Fire Extinguisher was last serviced November 2021. Carbon monoxide detector was tested and operational. Facility has had a recent servicing of their fire system and a recent inspection from the fire department as part of the Change of Ownership.

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: 03/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2