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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803860
Report Date: 06/02/2022
Date Signed: 06/02/2022 12:01:12 PM

Document Has Been Signed on 06/02/2022 12:01 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:CLEARWATER AT SONOMA HILLSFACILITY NUMBER:
496803860
ADMINISTRATOR:WHITACRE, DERRICKFACILITY TYPE:
740
ADDRESS:710 ROHNERT PARK EXPRESWAY ETELEPHONE:
(707) 710-7385
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY: 114CENSUS: DATE:
06/02/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:12 AM
MET WITH:Derrick Whitacre-AdministratorTIME COMPLETED:
12:00 PM
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Licensing Program Analyst(LPA) Dina Alviso, conducted a case management-incident inspection, and met with Administrator Derrick Whitacre, and Health Services Director Patricia Lundgren..

LPA reviewed several resident incident reports, and obtained additional information.

There were two incidents reported of two memory care residents that wandered out of the memory care unit unsupervised. In review of the incidents and interviews with staff, there will be a deficiency cited for the residents awol/wandering out of the memory care unit unsupervised-Deficiency 87705(b)(2) Care of persons with Dementia-see LIC809D.


The following deficiency was cited (see LIC 809D) from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and Appeal Rights provided to the Administrator.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/02/2022
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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Document Has Been Signed on 06/02/2022 12:01 PM - It Cannot Be Edited


Created By: Dina Alviso On 06/02/2022 at 11:31 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: CLEARWATER AT SONOMA HILLS
FACILITY NUMBER: 496803860

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/03/2022
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. ***Based on incident report Resident R1 & R2 eleoped from facility without staff knowledge , the facility failed to take safety measures to address behaviors such as wandering for residents R1 & R2
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Licensee agrees to ensure elopement plan; and address frequency of awol drills for staff-training with all MC staff, regarding elopment and wandering behaviors. Proof of training with participants signature, trainer, &
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which poses an immediate Health, Safety risk to residents in care. As per staff interviews and incident reports, residents left the facility w/out staff knowledge. In both cases they left facility & were alert by individuals that observed residents being at risk., one resident wandered away from the facility and the other resident wandered outside to the front of the assisted living facility.unsupervised.
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date of training; and elopement plan, as well as what is the facility plan for avoiding elopements, to be submitted to CCL by 6/15/22. Date for schedule staff training & elopement plan to be submitted to CCL by 6/3/22.

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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.
SUPERVISOR'S NAME:Hope DeBenedetti
LICENSING EVALUATOR NAME:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2022


LIC809 (FAS) - (06/04)
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