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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 577004529
Report Date: 03/11/2022
Date Signed: 03/11/2022 03:58:53 PM

Document Has Been Signed on 03/11/2022 03:58 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: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:
03/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Jesse Plenos, LicenseeTIME COMPLETED:
04:00 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 Analyst Jill Nakagawa arrived unannounced and met with Jesse Plenos, Licensee to conduct an annual inspection, focusing on Infection Control procedures and Covid-19 Protocols. The facility has a Mitigation Plan that was reviewed and approved on 07/29/2021. LPA observed postings on the front and side door showing the requirements for visitation at the facility: wearing a mask, maintaining social distance, and providing vaccination information. Facility is allowing outside visitation at this time. Visitors must sign the Visitors' Log, answering screening questions and providing vaccination information.

LPA signed the facility visitor sign-in sheet and Licensee took LPA's temperature. The facility documents resident and staff's temperatures daily. LPA conducted a walk-through of the facility with Licensee and observed COVID-19 precaution postings. Licensee stated staff clean and disinfect the facility at least once 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.

LPA observed a supply of PPE including gloves, N-95 respirators, and surgical masks. 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.

No deficiencies were noted.

No citations issued at this inspection.



SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2022
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 1