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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804009
Report Date: 11/09/2023
Date Signed: 11/09/2023 01:44:27 PM


Document Has Been Signed on 11/09/2023 01:44 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
SANTA ROSA RO, 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:13CENSUS: 9DATE:
11/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Administrator, Melissa GenetTIME COMPLETED:
01:50 PM
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Licensing Program Analyst (LPA) Victoria Bertozzi arrived unannounced to conduct an Annual Required inspection and was greeted by Licensee/Administrator, Melissa Genet.

LPA initiated a tour of the facility around 9:35am and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Water temperature in bathrooms used by residents measured at 110 and 1118 degrees F which are within the range of 105 to 120 degrees F allowed per regulation. Extra hygiene products and linens were available. Cabinet containing cleaning supplies was locked. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation. Medications were centrally stored and locked. Emergency food and water supplies are stored in the pantry.

Fire extinguishers were last serviced May 2023. Facility has a fire system that LPA is unable to test but us monitored and serviced by a vendor. Facility's most recent fire/disaster drill was conducted October, 2023.

Three staff files and six resident files were reviewed. Staff have required First Aid and CPR certificates. Administrator Certificate for Administrator, Melissa Genet expires December 1, 2023.. Medications and medication records were reviewed. Training records were also reviewed.

Licensee/Administrator to submit updates of the following documents by 12/09/2022:
LIC 308 Designated Administrator (if applicable)
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan (review and update if changes)
Infection Control Plan (if changes)
Liability Insurance

No deficiencies cited during this inspection.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria BertozziTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2023
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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