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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 577004529
Report Date: 03/13/2024
Date Signed: 03/13/2024 12:11:38 PM


Document Has Been Signed on 03/13/2024 12:11 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:CLOVER HOMEFACILITY NUMBER:
577004529
ADMINISTRATOR:PLENOS SR., JESSEE OFACILITY TYPE:
740
ADDRESS:412 CLOVER STREETTELEPHONE:
(530) 661-1167
CITY:WOODLANDSTATE: CAZIP CODE:
95695
CAPACITY:14CENSUS: 10DATE:
03/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Victoria Young, LicenseeTIME COMPLETED:
12:15 PM
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Licensing Program Analysts (LPAs) Jill Nakagawa and Stefanie Mutialu arrived unannounced to conduct an 1-Yr Annual Inspection on March 13, 2024.

Facility was toured both indoors and outdoors. LPAs inspected the physical plant, food service, medication, client and staff records. The outside of the facility was observed to be in good repair and safe for residents. The inside of the facility was observed to be in good repair. Bathrooms and showers were clean and in good repair. Hot water temperature was117.2 F . Facility was maintained at a comfortable temperature. Required amounts of stored and perishable foods were present. Bedrooms were observed to be in good repair and bedding, storage and lighting were adequate. Medication, chemicals and toxins were appropriately under lock and key. Smoke detectors/carbon monoxide detector were present. Maintained monthly. Facility is equipped with a fire sprinkler system and a central pull fire alarm. Fire extinguishers were fully charged and ready for emergency use and last serviced on 1/15/2024. First aid kit was fully stocked for use. Facility license was openly posted for viewing. Administrator certificate for Jessee Plenos was observed to be current and expires 8/1/2024. Three staff and 5 residents records were reviewed. .......... Continued on 809-C
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 03/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/13/2024
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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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: CLOVER HOME
FACILITY NUMBER: 577004529
VISIT DATE: 03/13/2024
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Continued from 809....

Facility has 9 ambulatory residents and 1 non-ambulatory resident which is within fire clearance allowances.

A review of staff records on 3/13/24 indicates that all facility staff who require caregiver background checks have received criminal record clearances and are current on their First Aid/CPR training. Facility to submit documentation of other employee training.

Other documents requested:
Proof of Liability Insurance
Resident Inventory Forms
Completed SOC341A forms

There were no deficiencies cited on this visit.

Exit interview conducted.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2024
LIC809 (FAS) - (06/04)
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