<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803860
Report Date: 04/17/2024
Date Signed: 04/17/2024 06:18:36 PM

Document Has Been Signed on 04/17/2024 06:18 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:CLEARWATER AT SONOMA HILLSFACILITY NUMBER:
496803860
ADMINISTRATOR/
DIRECTOR:		O'SULLIVAN, JANNAFACILITY TYPE:
740
ADDRESS:710 ROHNERT PARK EXPRESSWAY ETELEPHONE:
(707) 710-7385
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY: 114CENSUS: 80DATE:
04/17/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Janna O'Sullivan-Administrator & Janice Foster, Health and Wellness DirectorTIME VISIT/
INSPECTION COMPLETED:
06:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analysts (LPAs) Julie Florio and Dina Alviso arrived unannounced, to conduct a required 1-year annual inspection continuation visit and met with Janna O'Sullivan, Administrator, and Janice Foster, Health and Wellness Director.

LPAs reviewed eight resident files and 10 staff files. All resident files had required documentation. All staff files had current CPR/First Aid certificates. Six out six direct care staff files did not have the minimum required training, of which four files did not have documentation of required initial training and five files did not have documentation of required annual training.

Although the food supply was sufficient at prior facility visit, LPAs documented and obtained photographs of observed food that was found left uncovered on the kitchen counter and several instances of unsealed/uncovered food in the walk-in refrigerator and freezer as well as in the dried goods storage room in the main kitchen.

Documents which shall be updated include, but are not limited to, the following:

All required initial and annual training including medication administration training for MedicationTechnicians.
Proof of training regarding proper food storage per the Health and Safety Code for all kitchen staff.

Deficiencies are cited from the California Code of Regulations (CCRs), Title 22, Division 6, and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted with Administrator. Appeal rights provided.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE: DATE: 04/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/17/2024
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 3
Document Has Been Signed on 04/17/2024 06:18 PM - It Cannot Be Edited


Created By: Julie Florio On 04/17/2024 at 04:11 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: CLEARWATER AT SONOMA HILLS
FACILITY NUMBER: 496803860

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.69(a)
Other Provisions
(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on file/record review, the licensee did not comply with the section cited above in 4 out of 4 medication technician staff files/records lacked required inital and/or annual medication administration trainining documentation, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/18/2024
Plan of Correction
1
2
3
4
Licenssee to submit a plan of correction regarding how they will bring this citaion into complaince, including staff obtaining required medication training. Then follow up with proof of the minimum required medication training for idientified medication technicians (see documented staff names provided) within 45-days.
Type A
Section Cited
CCR
87555(b)(23)
General Food Service Requirements
(b) The following food service requirements shall apply: (23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on the observed food found left uncovered on the kitchen counter and several instances of unsealed/uncovered food in the walk-in refrigerator and freezer as well as in the dried goods storage room in the main kitchen, the licensee did not comply with the section cited above in several instances which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/18/2024
Plan of Correction
1
2
3
4
Facility to hold an in-service trainig with all kitchen staff regarding proper food storage. Submit a plan of correction regarding how they plan to correct this citation to bring the facility into compliance within 24-hours. Them submit proof of completed training for all kitchen staff within 10-days.
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:Bethany Moellers
LICENSING EVALUATOR NAME:Julie Florio
LICENSING EVALUATOR SIGNATURE:
DATE: 04/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 04/17/2024 06:18 PM - It Cannot Be Edited


Created By: Julie Florio On 04/17/2024 at 04:11 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: CLEARWATER AT SONOMA HILLS
FACILITY NUMBER: 496803860

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(1)
Other Provisions
(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on file/record review, the licensee did not comply with the section cited above in 4 out of 6 direct care staff files/records missing required inital trainining documentation, including medication administration training for medication technicians, and 5 out of 6 staff files/records missing required annual training which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/18/2024
Plan of Correction
1
2
3
4
Licenssee to submit a plan of correction regarding how they will bring this citaion into complaince, including staff obtaining required medication training. Then follow up with proof of the minimum required initial and annual medication training for idientified medication technicians (see documented staff names provided) within 30-days. Lastly, follow up within proof of the minimum required initial and annual training hours for identified staff (see documented staff names provided) completed within 45-days.

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:Bethany Moellers
LICENSING EVALUATOR NAME:Julie Florio
LICENSING EVALUATOR SIGNATURE:
DATE: 04/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2024


LIC809 (FAS) - (06/04)
Page: 3 of 3