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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 577004529
Report Date: 06/04/2026
Date Signed: 06/04/2026 02:03:22 PM

Document Has Been Signed on 06/04/2026 02:03 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, JESSEFACILITY TYPE:
740
ADDRESS:412 CLOVER STREETTELEPHONE:
(530) 402-1029
CITY:WOODLANDSTATE: CAZIP CODE:
95695
CAPACITY: 14CENSUS: 9DATE:
06/04/2026
TYPE OF VISIT:OfficeUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:24 AM
MET WITH:Jesse Plenos, Licensee & Victoria YoungTIME VISIT/
INSPECTION COMPLETED:
02:05 PM
NARRATIVE
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On 06/04/2026, an informal office meeting was conducted in the Santa Rosa Regional Office. Present in the meeting were Licensing Program Manager (LPM), Kimberley Mota, Licensing Program Analyst, (LPA) Jill Nakagawa, and Licensee, Jesse Plenos and Victoria Young .

The purpose of the informal office meeting was to discuss areas of non-compliance and observed ongoing Community Care Licensing (CCL) concerns of the operation of Clover Home. The Licensee was informed that this informal meeting is a part of the Administrative Action process and that further and/or repeat citations may result in a formal Non-Compliance Plan.

Items addressed in today's meeting include but are not limited to the following areas of concern:

Criminal record clearances and need for fingerprint clearances and associations of staff.

Reporting requirements of incidents occurred at the facility were not reported to CCL.

Elopements not reported to CCL.

Administrator not in place and/or missing proper documentation to appoint one.

Outstanding Plan of Corrections (POC's)

Deficiencies cited. See 809-D.

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 Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

NAME OF LICENSING PROGRAM MANAGER: Kimberley Mota
NAME OF LICENSING PROGRAM ANALYST: Jill Nakagawa
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/04/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 06/04/2026 02:03 PM - It Cannot Be Edited


Created By: Jill Nakagawa On 06/04/2026 at 12:02 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: CLOVER HOME
FACILITY NUMBER: 577004529

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/04/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/04/2026
Section Cited
CCR
87705(b)(2)

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87705Care of Persons with Dementia(b)In addition...the plan of operation shall address the needs of residents with Dementia (b)(2)Safety measures to address behaviors...wandering, ingestion of toxic materials. This requirement is not met as evidenced by:
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POC: Licensee to ensure all residents whose physician's reports require residents not to leave facility unattended are supervised. Licensee to provide proof of audit of 602's for all residents currently in facility by 6/5/2026.
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Based on Incident and reports from outside parties that resident (R1) was allowed to go outside the facility unattended, which according to R1's physician's report is not allowed. This poses an immediate helath, safety, or personal rights risk to persons in care.
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A civil penalty of $500 has been assessed Per Health & Safety Code 1568.0822(a)(3).
Type B
06/04/2026
Section Cited
CCR87405(a)

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87405 Administrator-Qualifications and Duties (a)All facilities shall have a qualified and currently certified administrator. This requirement is not met as evidenced by:
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Licensee to submit documents for placement of Administrator to CCL by 6/11/2026.
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Based on LPA's interviews and records review, the licensee did not comply with the section cited above in that Licensee did not have a documented Administrator in place within 30 days. This poses a potential risk to health, safety or personal rights to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kimberley Mota
NAME OF LICENSING PROGRAM MANAGER:
Jill Nakagawa
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2026


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: 06/04/2026
NARRATIVE
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 The Dept. received incident and outside reports that resident (R1) left the facility unattended. Staff (S1) called police for assistance in locating R1, who had been missing for at least 15 minutes. R1 was found by employee approximately 45 minutes later on Kentucky Street. Deficiency cited. See 809-D. Civil penalty issued in the amount of $500 per HSC..

The Dept. is issuing a citation for failure to report. The above incident was not reported to the Department in a timely manner. Deficiency cited.

The Licensee has not placed an Administrator within the 30-Day timeframe required. Deficency cited.

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 Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

NAME OF LICENSING PROGRAM MANAGER: Kimberley Mota
NAME OF LICENSING PROGRAM ANALYST: Jill Nakagawa
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2026
LIC809 (FAS) - (06/04)
Page: 5 of 5
Document Has Been Signed on 06/04/2026 02:03 PM - It Cannot Be Edited


Created By: Jill Nakagawa On 06/04/2026 at 01:20 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: CLOVER HOME
FACILITY NUMBER: 577004529

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/04/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/04/2026
Section Cited
CCR
87211(a)(1)(D)

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87211 Reporting Requirements (1)A written reort shall be submitted to the licensing agency and to the person responsible for the resident within 7 days of the occurrence of any of the events specified in (A) through (D) below...This requirement is not met as evidenced by:
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LIcensee to ensure incidents are reported per regulation. Licensee agrees to review regulation 87211 and conduct training for all staff on reporting requirements. Evidence of completed training to be submitted to CCL by POC date of 6/11/2026.
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Based on LPA's records review of facility and outside agencies the licensee failed to notify the deaprtment within 7 days of R1's elopement which poses a potential risk to the health and safety of residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kimberley Mota
NAME OF LICENSING PROGRAM MANAGER:
Jill Nakagawa
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2026


LIC809 (FAS) - (06/04)
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