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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804009
Report Date: 12/20/2024
Date Signed: 12/20/2024 03:15:54 PM

Document Has Been Signed on 12/20/2024 03:15 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/
DIRECTOR:		GENET, MELISSAFACILITY TYPE:
740
ADDRESS:611 CHERRY CREEK ROADTELEPHONE:
(707) 367-2725
CITY:CLOVERDALESTATE: CAZIP CODE:
95425
CAPACITY: 13CENSUS: DATE:
12/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:59 AM
MET WITH:Melissa Genet, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by Administrator Melissa Genet: Administrator Certificate 7021074740 expires 12/1/25. Facility contact information was reviewed.

At approximately 11:00am LPA and Admin toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered. Hall closet containing cleaning supplies was locked. Kitchen drawer with sharp knives locked. LPA observed prescription milk of magnesia on an open shelf in the kitchen along with thickener. LPA discussed with Admin keeping all medication, including over the counter items and nutritional supplements in the medication closet as it must remain inaccessible to residents. Admin immediately removed items from shelf and secured them in the medication cabinet.

The main bathroom across from the living room has a little closet that houses the sprinkler equipment. The door to the closet is splintering and cracking at the bottom posing a safety hazard to residents. The main bath next room #9 had a leak under the sink. The leak has been fixed but the wood/plywood/sheathing on the bottom/base of the vanity cabinet has a black substance present with spots and dots of a white fuzzy substance (deficiencies cited, see 809D)

All bedrooms were equipped with lighting, night stand, and chest of drawers, except for resident (R2). R2 did not have a lamp. Admin says they broke it and family doesn't want another one in there. LPA advised get a note from the family and put it in the resident's file. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Resident bathroom had required bath mat and grab bar. Water temperature in sink accessible to residents in care measured at 108.6 degrees F which is within the allowable range of 105 to 120 degrees F.

Continued on 809C...
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE: DATE: 12/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: CLOVERDALE BETTER LIVING SENIOR CARE
FACILITY NUMBER: 496804009
VISIT DATE: 12/20/2024
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Continued from 809...

Fire extinguishers were last inspected 3/29/24. Smoke/Carbon Monoxide detectors and sprinklers located throughout the facility are hardwired and serviced by a vendor. Most recent date of service was March 2023 and service sticker indicates that it is a 5 year inspection. Facility’s last quarterly disaster drills were conducted 10/15/24.

Facility is part of a community that share a water source. Community currently has extremely high levels of arsenic in the water. Previous to this annual inspection, facility Admin reported water issue to CCL and CCL has been in communication with the Dept of Health and the Water Board. A solution to this water issue is currently being developed between all involved parties. However, the facility water is dangerous for human consumption and cannot be ingested, although it can be sued for bathing. The facility is using paper dishes and utensils and/or washing all cooking pots, cups, and utensils in boiled water, ensuring the temperature is maintained within regulation of at least 170 degrees F. LPA observed notice posted disclosing water warning above the guest book sign in. LPA and Admin discussed adding a notice above facility sinks in residents rooms, and in the kitchen. Admin will provide pictures of added notices to CCL no later than 12/23/24.


At approximately 12:15pm LPA conducted a review of 5 resident records. Residents R1, R2, and R4 did not have current physician's reports on file or a current appraisal. R3 did not have a current appraisal on file (deficiencies cited, see 809D). LPA observed full bed rails being used on R1’s bed. Based on LPA interview with Administrator, the facility has not requested an exception for the full bed rails from the CCL as required. Administrator agreed to submit pertinent documents to CCL for review by no later than 12/30/24.

At approximately 1:00pm LPA conducted review of 5 staff records. All continuing staff have not completed the required 20 hours of annual training, and staff (S3) is a new hire as of 2024 and has not completed the required 40 hours of training (deficiency cited, see 809D). S1 did not have a Health Screen on file (deficiency cited, see 809D)

At approximately 2:00pm LPA and Admin conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024
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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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: CLOVERDALE BETTER LIVING SENIOR CARE
FACILITY NUMBER: 496804009
VISIT DATE: 12/20/2024
NARRATIVE
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Continued form 809C...

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC500- Personnel Report
LIC308- Designation of Responsibility
Liability Insurance

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Admin. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with Administrator and a copy of this report was given.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024
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Document Has Been Signed on 12/20/2024 03:15 PM - It Cannot Be Edited


Created By: Christi Coppo On 12/20/2024 at 02:38 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: CLOVERDALE BETTER LIVING SENIOR CARE
FACILITY NUMBER: 496804009

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA and Admin observation and record review, the licensee did not comply with the section cited above in that S1 did not have a Health Screen on file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/03/2025
Plan of Correction
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Facility to submit picture of completed Health Screen for S1 by plan of corrrection due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Victoria Bertozzi
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2024


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Document Has Been Signed on 12/20/2024 03:15 PM - It Cannot Be Edited


Created By: Christi Coppo On 12/20/2024 at 02:38 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: CLOVERDALE BETTER LIVING SENIOR CARE
FACILITY NUMBER: 496804009

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA and Admin observation, the licensee did not comply with the section cited above in that he main bathroom across from the living room has a little closet that houses the sprinkler equipment. The door to the closet is splintering and cracking at the bottom posing a safety hazard to residents. The main bath next room #9 has a wood/plywood/sheathing on the bottom/base of the vanity cabinet has a black substance present with spots and dots of a white fuzzy substance, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/10/2025
Plan of Correction
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Facility to submit pictures of replaced bottom of cabinet in bathroom next to rm #9 and submit picture of replaced door on closet in main bathroom across from living room by plan of crrection due date.
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA and Admin observation, interview, and record review, the licensee did not comply with the section cited above in that all continuing staff have not completed the required 20 hours of annual training, and staff (S3) is a new hire as of 2024 and has not completed the required 40 hours of training, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/06/2024
Plan of Correction
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Facility to submit proof of 4 hours of training for S1, S2, S4, S5 and 24 hours of training for S3 by plan of correction due date. Proof to include topic (which needs to meet regualtion requriements of topics), date of training completed, and duration of hours completed,
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Victoria Bertozzi
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/20/2024 03:15 PM - It Cannot Be Edited


Created By: Christi Coppo On 12/20/2024 at 02:38 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: CLOVERDALE BETTER LIVING SENIOR CARE
FACILITY NUMBER: 496804009

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(c)
Reappraisals
(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA record review, the licensee did not comply with the section cited above in that R3 did not have a curent appraisal on file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/27/2024
Plan of Correction
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Facility to submit appraisal for R3 by plan of correction due date
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation and record review, the licensee did not comply with the section cited above in that R1, R2, and R4 did not have a current physician's report or a current appraisal (both) on file, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/10/2025
Plan of Correction
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Facility to submit to CCL physician's reports and appraisals for R1, R2, and R4 by plan of correction due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Victoria Bertozzi
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2024


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