577004529-7-14-2026-21-AS-KMOA-DWPKXC-20260806081715

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 577004529
Report Date: 07/14/2026
Date Signed: 07/14/2026 01:13:57 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/07/2026 and conducted by Evaluator Jill Nakagawa

COMPLAINT CONTROL NUMBER: 21-AS-20260407125537

FACILITY NAME:	CLOVER HOME		FACILITY NUMBER:	577004529
ADMINISTRATOR:	PLENOS, JESSE		FACILITY TYPE:	740
ADDRESS:	412 CLOVER STREET		TELEPHONE:	(530) 402-1029
CITY:	WOODLAND	STATE: CA	ZIP CODE:	95695
CAPACITY:	14	CENSUS: 8	DATE:	07/14/2026
		UNANNOUNCED	TIME BEGAN:	11:50 AM
MET WITH:	Charlotte Lewis, Acting Administrator		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Staff are locking residents in the facility.
Staff are not providing comfortable accommodations for residents in care.
Staff do not prevent vulnerable residents from leaving the facility without care, supervision or assistance.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Nakagawa arrived unannounced to conduct an investigation and deliver findings regarding the above allegations. There were 8 residents and 3 staff at the time of visit. LPA met with Charlotte Lewis, the acting Administrator.

The complaint alleges that Staff are locking residents in the facility. The complainant states that R1complained that staff locked them in after another resident eloped. LPA inspected the facility on two separate occasions (04/09/2026, 07/14/2026) and found no internal locks on doors that required keys. All doors leading to the exterior of facility were unlocked or able to be unlocked without a key for residents to safely evacuate the building. There are five residents who are independent. LPA was able to interview 4 of those residents and asked if they were able to leave the building unattended; 4 of 4 said they are able to do so.
(Continued on 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20260407125537

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/14/2026

NARRATIVE

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(Continued from 9099)
***THIS PAGE OF REPORT HAS BEEN AMENDED***

Based on the interviews of residents and LPA’s observations the allegation that staff are locking residents in the facility is Unsubstantiated. Although the allegation may have occurred there is not a preponderance of evidence therefore the allegation is Unsubstantiated.

The complaint alleges that Staff are not providing comfortable accommodations to residents in care. The complainant states that staff recently placed a second resident in a now shared room and positioned the second bed in front of the sliding glass door. LPA inspected all bedrooms in the facility and found there were no beds in front of a sliding glass door obstructing the exit and that required furniture was present. The facility has a fire clearance and is licensed for two beds for each of the bedrooms. The resident (R1) living in the room under investigation was not paying for a private room and therefore the addition of a roommate would have been allowed under the lease agreement. Based on the fire clearance, the lease agreement and observations the allegation that Staff are not providing comfortable accommodations to residents in care is unsubstantiated. Although the allegation may have occurred there is not a preponderance of evidence therefore the allegation is unsubstantiated.

The complaint alleges that Staff do not prevent vulnerable residents from leaving the facility without care, supervision or assistance. The complainant states that the resident (R1) dislikes the facility and tries to leave often and has been brought back to the facility in the past by the Police. LPA reviewed police records and found that R1 made multiple 911 calls but according to police reports R1 was found to be safe within the facility. Based on review of police reports the allegation that Staff do not prevent vulnerable residents from leaving the facility without care, supervision or assistance is Unsubstantiated. Although the allegation may have occurred there is not a preponderance of evidence to to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Amended Report (Page 9099-C) was reviewed with Acting Administrator Charlotte Lewis via phone and signed by Carestaff Isabell Ruiz on 7/29/2026.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2026

LIC9099 (FAS) - (06/04)

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