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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 577004529
Report Date: 03/21/2025
Date Signed: 03/21/2025 12:29:35 PM

Document Has Been Signed on 03/21/2025 12:29 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/
DIRECTOR:
PLENOS SR., JESSEE OFACILITY TYPE:
740
ADDRESS:412 CLOVER STREETTELEPHONE:
(530) 661-1167
CITY:WOODLANDSTATE: CAZIP CODE:
95695
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 9DATE:
03/21/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Jessee Plenos, Sr., Licensee/AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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Licensing Program Analysts (LPAs) Jill Nakagawa arrived unannounced to conduct an 1-Yr Annual Inspection on March 21, 2025.

Facility was toured both indoors and outdoors. LPA 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 was108.9 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 locked and inaccessible to residents. 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 1/10/2025. First aid kit was fully stocked for use. Facility has 7 ambulatory residents and 2 non-ambulatory residentsb which is within fire clearance allowances.

A review of staff records on 3/21/2025 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.


There were no deficiencies cited on this visit.

Exit interview conducted.
Kimberley MotaTELEPHONE: (707) 588-5051
Jill NakagawaTELEPHONE: 707-588-5063
DATE: 03/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/21/2025
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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