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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803860
Report Date: 08/20/2025
Date Signed: 08/20/2025 03:14:33 PM

Document Has Been Signed on 08/20/2025 03:14 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:
08/20/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:James Homer-AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alviso conducted a case management inspection, on 8/20/2025 at approximately 9:40am, and met with Executive Director, James Homer.

This case management is to review resident incidents' of R1 AWOLs/wandering away from the facility.

LPA reviewed resident, R!, records, and obtained additional information on incidents. R1 resides in assisted living area of the building. Resident R1 who uses a four wheeled walker that has a wander-guard attached to it. Wander-guard is to alert facility staff if resident wanders out of any exit door/gate. R1 is not to be in the community/out of the facility unsupervised per medical assessment, and review of resident records. R1 exited and AWOL the facility without staff’s knowledge on 8/14/25, 8/2/25, 6/6/25, and 5/8/25.

On 8/14/25 , resident wandered away and an individual saw R1 and contacted the Police. Staff had not located R1 and called 911; R1 was returned to the community by the Police department. On 8/2/25 R1 was not in their room when staff came to take them to their dinner meal, staff searched inside and outside the facility, when a staff observed R1 walking into the front entrance of the building on their own. On 6/6/25 R1 exited the facility without staff’s knowledge, R1 was observed outside by the trash cans/dumpster by a maintenance staff who was arriving to work. Staff parked their vehicle and went and found R1 sitting in a staff’s parked car. Facility staff redirected R1 back into the facility. On 5/8/25 staff found R1 wandering around outside the facility.

Regulation Reappraisals- 87463, this shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition, including those required to be documented as specified in Section 87466, Observation of the Resident. Behavioral expression, as defined in Section 87101, Definitions, that may result in harm to self or others, such as unsafe wandering, elopement, hallucinations, lacking in hazard awareness, or lacking in impulse control
Continued on LIC809C..
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Dina Alviso
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2025
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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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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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: 08/20/2025
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Facility is to update the resident's care plan after the reappraisal as needed. R1's care plan shall meet resident's current needs, and all health & safety hazards need to be addressed in the care plan, ensuring sufficient staffing to meet these identified needs. Per record reviews, R1 does not reside in memory care, and staff are to ensure all resident's needs are met, including behavior of wandering away from the facility. R1 does have a wander-guard on their walker they use to ambulate but has continued to awol the facility without staff's knowledge and/or supervision.

Per record review, The Department was not in receipt of R1’s AWOL incidents that occurred on 5/8/25 and 6/6/25; This is a required report, per regulations.

The following deficiencies will be cited, LIC809D.


87463(g)(j) Reappraisals-The licensee shall ensure corresponding changes are made in the care and supervision provided to the resident. The licensee shall evaluate staffing needs to ensure that there is a sufficient number of direct care staff, as specified in Section 87411, Personnel Requirements – General, to support each resident's physical, social, emotional, safety and health care needs, as identified in their current appraisal.

87211(a)(1)-Reporting Requirements-Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.

The following deficiencies were cited from the California Code of Regulations, Title 22, Division 6, Chapter 8 of California Regulation and/or Health & Safety Code.



Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.
Exit interview conducted with the Administrator James Homer.
Appeal rights provided.
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Dina Alviso
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/20/2025 03:14 PM - It Cannot Be Edited


Created By: Dina Alviso On 08/20/2025 at 02:15 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: 08/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/20/2025
Section Cited
CCR
87463(g)(1)

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87463(g)(j) Reappraisals-The licensee shall ensure corresponding changes are made in the care and supervision provided to the resident. The licensee shall evaluate staffing needs to ensure that there is a sufficient number of direct care staff, as specified in Section 87411, Personnel Requirements – General, to support each resident's physical, social, emotional, safety and health care needs, as identified in their current appraisal.
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Licensee to ensure that R1's care plan reflects current needs of the resident, and ensure sufficienting staffing at all times to ensure all R1's needs are met, including not exiting the building without staff's knowledge and supervision.
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Per review of records, R1 is not to be in the community/out of the facility unsupervised per medical assessment, and review of resident records. R1 exited and AWOL the facility without staff’s knowledge on 8/14/25, 8/2/25, 6/6/25, and 5/8/25. This is a risk to health & safety of resident in care.
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Submit how the facility plans to meet R1's current needs, including their wandering/awol behavior, helping to ensure R1's health & safety. Proof of correction to be submitted by 8/25/25.
POC due by 8/21/25.
Type B
09/05/2025
Section Cited
CCR87211(a)(1)-

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87211(a)(1)-Reporting Requirements-Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case
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Licensee to ensure all resident incidents are reported as required per regulations. Submit incident reports on R1 of AWOL occurrences on 6/6/25, and 5/8/25. Submit plan of future compliance with this regulation. POC due 9/5/25.
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Per record review, The Department was not in receipt of R1’s AWOL incidents that occurred on 5/8/25 and 6/6/25. This is a risk to personal rights and/or health & safety of resident 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.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Dina Alviso
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2025


LIC809 (FAS) - (06/04)
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