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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 577004529
Report Date: 06/17/2021
Date Signed: 06/17/2021 08:09:17 PM

Document Has Been Signed on 06/17/2021 08:09 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:CLOVER HOMEFACILITY NUMBER:
577004529
ADMINISTRATOR:PLENOS SR., JESSEE OFACILITY TYPE:
740
ADDRESS:412 CLOVER STREETTELEPHONE:
(530) 661-1167
CITY:WOODLANDSTATE: CAZIP CODE:
95695
CAPACITY: 14CENSUS: 8DATE:
06/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Jessee Plenos, Licensee and AdministratorTIME COMPLETED:
08:15 PM
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Licensing Program Analysts (LPAs) Karina Canela and Jill Nakagawa arrived unannounced to conduct an Annual Required inspection and met with Jessee Plenos, Licensee. The annual inspection is focused on the Infection Control procedures and practices of this Residential Care Facility for the Elderly.

LPAs signed the facility visitor sign-in sheet and Licensee took LPA's temperatures. LPAs discussed with Licensee to document COVID-19 screening questionnaire for visitors to the facility. Licensee stated staff and resident's temperatures are taken 2 to 3 times a day. The facility documents resident and staff's temperatures daily. LPAs conducted a walk-through of the facility with Licensee and observed COVID-19 precaution postings. Licensee stated staff clean and disinfect the facility twice a day. The facility has a visitation plan, provides virtual visits for medical needs, and phone calls for family to stay in contact with residents. All staff wore a face mask during this visit.

LPAs observed a supply of PPE including gloves, N-95 respirators, and surgical masks. LPAs provided gowns to Licensee during today's visit. The facility has submitted a COVID-19 Mitigation Plan Report on Epidemic Outbreaks specific to COVID-19 to the California Department of Social Services for review.

Facility staff to document and completed training on PPE use, isolation policies, and infection prevention. N-95 respirator Fit testing (Cal/OSHA requirement) is in process.



Report continued on LIC809-C
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE: DATE: 06/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/17/2021
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
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: CLOVER HOME
FACILITY NUMBER: 577004529
VISIT DATE: 06/17/2021
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During the inspection, LPAs observed the following:

Medications unlocked & accessible to residents in care:
  • Resident (R1)'s refrigerated prescribed medication (Lactulose Sol, 473 ML bottle) observed unlocked and accessible within the facility kitchen refrigerator.
  • 3 bottles (Tylenol, Aller-Tec, B-100 B-Complex vitamins), 1 tube of Triple Antibiotic & Pain Relief, and Suphedrine PE Nasal Decongestant Phenylephrine HCL Tablets belonging to R2 and observed in their bedroom (#4).
  • 1 bottle of Advil,3 bottles of vitamins (Raw Vitamin C, Cal-Mag Citrate, Turmeric vitamin capsules) belonging to R3 and observed unlocked in their bedroom (#4).
  • 1 tube of Diclofenac Sodium Topical Gel belonging to R4 and observed unlocked in their bedroom (#8).
Licensee stated he would obtain a lock box for the inside of the refrigerator to lock refrigerated medication. Licensee stated he understood the regulation requirement. LPAs reviewed resident files. LPAs verified R1, R2, R3, and R5 (R4's roommate) Medical Physician Report (LIC 602) section #16 a. states the residents are not able to administer their own prescription medications. LPAs verified 5 of 8 residents are not able to administer their own prescription medications per their LIC 602.

Toxins observed unlocked and accessible to residents in care:
  • 1 gallon house paint can, 2 Gallons of Clorox, 2 bottles of Pinesol, 1 bottle of wood cleaner, and container of liquid insect killer repellant was observed unlocked and accessible in a closet located at the front entrance of the facility.
Licensee stated it would be corrected immediately with a pad lock on the door.

Fire Safety:

  • 5 of 5 fire extinguishers located throughout the main hallway of the facility and kitchen area, was observed to be charged and last serviced 11/12/2018.
Licensee stated the fire extinguishers are serviced yearly as required, however due to the 2020 COVID-19 Pandemic, the facility has been unable to have the fire extinguishers serviced. The facility will have the fire extinguishers serviced next week per licensee's statement.


Report continued on LIC809-C...
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2021
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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: CLOVER HOME
FACILITY NUMBER: 577004529
VISIT DATE: 06/17/2021
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Locked food:
  • Canned goods & Dry Foods stored in the kitchen walk-in pantry was observed to have a key padlock on the exterior to the pantry door. Licensee stated the facility locks the door leading to the kitchen/dining room and living room.
Licensee stated the facility staff lock the pantry at night to guard against "contamination" by residents. LPAs explained the facility can not lock any food for residents as it is a personal rights violation. Licensee stated he understood the regulation requirement and stated he would not continue to lock any food.



Appeal Rights Provided.
Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiencies and/or repeat deficiencies within a 12 month period may result in civil penalties.
Exit interview conducted with Licensee Jessee Plenos, whose signature below confirms receipt of this report.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2021
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 06/17/2021 08:09 PM - It Cannot Be Edited


Created By: Karina Canela On 06/17/2021 at 06:29 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
, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: CLOVER HOME
FACILITY NUMBER: 577004529

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/17/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/18/2021
Section Cited

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87465 Incidental Medical and Dental Care: (h)The following requirements shall apply to medications which are centrally stored(2)...shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement was not met as evidenced by:
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Based on LPAs observations and interviews conducted, Licensee did not ensure the regulation above due to Resident (R1, R2, R3, R4) medication observed unlocked and accessible in resident bedrooms. This poses an immediate health and safety risk to residents in care.
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Licensee to obtain a lock box for refrigerated resident's medication. Licensee to submit statement, training documentation, & pictures of medication lock box to Community Care Licensing as Proof of Correction (POC). Statement due date 06/18/2021. Training documentation and POC pictures due 06/24/21.
Type A
06/18/2021
Section Cited

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87309 Storage Space:
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
This requirement was not met as evidenced by:
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Based on LPAs observations and interviews conducted, Licensee did not ensure the regulation above due to disinfectants, cleaning solutions, insect poison, and house paint observed unlocked and accessible to residents. This poses an immediate health and safety risk to residents in care.
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Licensee to submit statement and training documentation to Community Care Licensing as Proof of Correction (POC). Statement due date 06/18/2021. Training documentation due 06/24/21.
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:Karina Canela
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/17/2021 08:09 PM - It Cannot Be Edited


Created By: Karina Canela On 06/17/2021 at 06:51 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
, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: CLOVER HOME
FACILITY NUMBER: 577004529

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/17/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/28/2021
Section Cited

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87203 Fire Safety - All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.
This requirement was not met as evidenced by:
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Based on LPAs observations and interviews conducted, Licensee did not ensure the regulation above due to 5 of 5 fire extinguishers which were charged but not serviced (last serviced 11/12/2018). This poses a potential health and safety risk to 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.
SUPERVISOR'S NAME:Hope DeBenedetti
LICENSING EVALUATOR NAME:Karina Canela
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2021


LIC809 (FAS) - (06/04)
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