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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 577004529
Report Date: 08/14/2026
Date Signed: 08/20/2026 08:59:05 AM

Document Has Been Signed on 08/20/2026 08:59 AM - 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:		LEWIS, CHARLOTTEFACILITY TYPE:
740
ADDRESS:412 CLOVER STREETTELEPHONE:
(530) 402-1029
CITY:WOODLANDSTATE: CAZIP CODE:
95695
CAPACITY: 14CENSUS: 8DATE:
08/14/2026
TYPE OF VISIT:Case Management - Legal/Non-complianceANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Jesse Plenos, Licensee,Umesh Pandey, Applicant, Charlotte Lewis, Administrator, Kimberley Mota, Licensing Program Manager, Carla Nuti-Martinez, Regional ManagerTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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On 08/14/2026, a Non-Compliance Conference was conducted in the Santa Rosa Regional Office. Present in the meeting were Regional Manager Carla Nuti-Martinez, Licensing Program Manager (LPM), Kimberley Mota, Licensing Program Analyst (LPA) Jill Nakagawa, Licensee, Jesse Plenos and Victoria Young, Applicant Umesh Pandey(via Teams) and Administrator Charlotte Lewis.

The purpose of the meeting was to discuss areas of non-compliance observed and ongoing concerns of the operation of Clover Home. The Licensee was informed that this Non-Compliance Conference is a part of the Administrative Action process and due to continuing citations and areas of concern the facility will be placed on a formal Non-Compliance Plan. Also discussed was applicant's non-compliance conference held on 7/21/2026 with the Sacramento South Regional office regarding concerns of similar nature for the applicants facility Lakewood Villa Care Center #342701553.

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.
  • Care and Supervision
  • Maintenance and Operations
  • Medication Management
  • Health and Safety
  • Food Service
  • Elopement Procedures
  • Reporting requirements of incidents not reported in a timely manner
  • Administrator Qualifications and Duties
Deficiencies cited. See 809-D.

(Continued on 809-C)

Kimberley Mota
Jill Nakagawa
DATE: 08/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/14/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
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 08/20/2026 08:59 AM - It Cannot Be Edited


Created By: Jill Nakagawa On 08/14/2026 at 08:39 AM
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: 08/14/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/14/2026
Section Cited
CCR
87705(b)(2)

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87705(b)(2)Care of Persons with Dementia - Safety measures to address behaviors such as wandering. This requirement is not met as evidenced by:*
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Licensee/applicant agrees to ensure elopement plan is followed. Licensee/applicant to conduct staff training regarding elopment and wandering behaviors. Proof of training with participants signature, trainer, & date of training;
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**Based on observations of LPA on 8/7/2026, Resident R1 eloped from facility without continued staff supervision; the facility failed to take adequate safety measures to address behaviors such as wandering for resident R1 which poses an immediate Health, Safety risk to residents in care.
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and elopement plan training dates to be submitted to CCL by 8/17/2026.
**An immediate repeat civil penalty in the amount of $500 is assesed.
Type B
08/14/2026
Section Cited
CCR87307(b)

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87307 Personal Accommodations and Services (b) Toilets and bathrooms shall be conveniently located. The licensed capacity shall be established based on Section 87158, Capacity, and the following:
(1) At least one toilet and washbasin for each six (6) persons.. This requirement is not met as evidenced by:Based on LPA's observations,there was only
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Licensee to self- verify that there is at least one bathroom per 6 residents and send LPA notification by 8/17/2026.
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one bathroom in service for 8 residents, not 6, which is stated in regulation which poses a potential risk to the 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: 08/14/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2026


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: 08/14/2026
NARRATIVE
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On 8/7/26, Resident (R1) was able to leave the facility unassisted. Staff attempted to redirect R1 who was then able to leave on foot while wearing socks and temperatures approximately 102 degrees. S1 followed R1 briefly and then returned to the facility stating "it is too hot". LPA requested facility contact Woodland Police to search for R1 who was found by police and returned to the facility.

During the conference it was discussed the facility had undergone a bathroom remode lwithout notification to Community Care Licensing (CCL). Applicant informed CCL during the non-compliance conference that the renovations took no more than 1 week. It was confirmed the remodel was completed on 8/7/2026. LPA observed renovations during visit on 7/21/2026. Facility was informed that building changes must be reported in advance, including resident impacts and and plans to comply with Regulation 87307(b).

Per discussion, applicant appointed Charlotte Lewis as the Administrator. Although acting as the Administrator, Ms. Lewis's Administrator Certificate Expired 8/8/26. Ms. Lewis stated that paperwork was submitted to the Administrator Renewal unit in February, 2026, there is no documentation of it being received.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Exit interview was conducted with Administrative Assistant and a copy of this report was given.



An immediate civil penalty is being assessed today in the amount of $500.00 due to a repeat violation for regulation 87705(b)(2).
NAME OF LICENSING PROGRAM MANAGER: Kimberley Mota
NAME OF LICENSING PROGRAM ANALYST: Jill Nakagawa
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2026
LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 08/20/2026 08:59 AM - It Cannot Be Edited


Created By: Jill Nakagawa On 08/14/2026 at 01:05 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: 08/14/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/17/2026
Section Cited
CCR
87405(b)

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87405 Administrator - Qualifications and Duties (b)The administrator of a facility or facilities shall have the responsibility and authority to carry out the policies of the licensee.This requirement was not met as evidenced by:
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Licensee to ensure that there is a certified Administrator to submit proof of renewal submission or facility to submit change of Administrator within 10 days.
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the list of Administrator Certification List, S1 was not found on the Current or pending list of administrators, which is a potential risk to the residents in care.
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Licensee/applicant to submit proof to CCL by POC date 8/18/26.

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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: 08/14/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2026


LIC809 (FAS) - (06/04)
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