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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803860
Report Date: 03/24/2025
Date Signed: 03/24/2025 05:13:44 PM

Document Has Been Signed on 03/24/2025 05:13 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:		HOMER, JAMESFACILITY TYPE:
740
ADDRESS:710 ROHNERT PARK EXPRESSWAY ETELEPHONE:
(707) 710-7385
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY: 114CENSUS: DATE:
03/24/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:James Homer-AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:25 PM
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Licensing Program Analysts (LPA) Alviso conducted a Required- 1 Year visit, on 324/25, at approximately 2:00pm, and met with James Homer, Administrator.

Facility has an approved dementia plan of operation. There is an approved hospice waiver for eighteen (18) residents. Facility has an infection control plan as required. The facility has a required emergency & disaster plan. Fire clearance is approved for one hundred fourteen (114) non-ambulatory, of which six (6) may be bedridden.

LPA reviewed staff files.

LPA toured the facility with the Administrator James Homer. Hot water was measured at 115.5 degrees Fahrenheit. All exits were free and clear of obstruction. All stairwells had the required evacuation chair, and user instructions posted. All required postings were up and visible to all residents, visitors, and staff. Facility has required emergency "72 hour shelter in place" supplies. Medications were centrally stored and locked in the assisted living area and in the memory care area. LPA observed that each medication room has a refrigerator for storing refrigerated medications. Food supply was observed to be sufficient.

LPA is requesting the following documents be updated and submitted by 4/24/25:
LIC308 - Designation of Administrator Responsibility
LIC500 - Personnel Report
LIC610E-Emergency Disaster Plan (ensure to review and update as needed/required)
Infection Control Plan (ensure to review and update as needed/required)
Copy of LIC400 Handling of Client Cash Resources (include copy of surety bond if handling cash)
Copy of Current Liability Insurance

Continued on LIC809C
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Dina Alviso
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/24/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HILLS
FACILITY NUMBER: 496803860
VISIT DATE: 03/24/2025
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During today's inspection the LPA observed the following deficiency:

LPA observed open commercial size boxes/bags of chocolate chips, pancake mix, walnuts, horchata drink mix, and jello pudding mix, open in the kitchen/pantry with no means to close the packages securely in order to prevent them from potential contamination. The Administrator and the Kitchen Chef discarded the items during the kitchen inspection. LPA obtained pictures for the file. This deficiency will be cited, 87555(b)(9)- General Food Service Requirements- The following food service requirements shall apply: Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service, see LIC809D.

California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited. Failure to correct deficiency (s) by due date (s), may result in additional deficiency citations and/or civil penalties being assessed.

Exit interview conducted with the Administrator James Homer
Appeal Rights Provided.

LPA will continue the annual inspection at a later date.

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Dina Alviso
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/24/2025 05:13 PM - It Cannot Be Edited


Created By: Dina Alviso On 03/24/2025 at 04:56 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: 03/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(9)
87555(b)(9)- General Food Service Requirements- The following food service requirements
shall apply: Procedures which protect the safety, acceptability and nutritive values of food
shall be observed in food storage, preparation and service.

This requirement is not met as evidenced by:
Deficient Practice Statement
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LPA observed open commercial size boxes/bags of chocolate chips, pancake mix, walnuts, horchata drink mix, and jello pudding mix, open in the kitchen/pantry with no means to close the packages securely in order to prevent them from potential contamination. LPA obtained pictures for the file, the licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/25/2025
Plan of Correction
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Licensee to ensure food supplies are stored appropriately, using procedures which protect the safety, acceptability and nutritive values of food items. Submit plan of correction in how the facility will correct the deficiency, and the plan to hold an in-service training with staff on the policy and procedures of food storage. Proof of training to, include trainer, topics, date, time spent, attendees, and employee signatures. Submit proof of training by 4/1/25. Submit plan of correction by 3/25/25.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Bethany Moellers
LICENSING EVALUATOR NAME:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 03/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2025


LIC809 (FAS) - (06/04)
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