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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 577004529
Report Date: 03/28/2023
Date Signed: 03/28/2023 02:06:13 PM

Document Has Been Signed on 03/28/2023 02:06 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: 9DATE:
03/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Jessee Plenos, Sr.TIME COMPLETED:
02:10 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 (LPA) Jill Nakagawa arrived unannounced to conduct an 1-Yr Annual Inspection.

Facility was toured both indoor and outdoors. LPA inspected the physical plant, food service, medication, client and staff records. The outside of the facility was observed to be in good repair and safe for residents. The inside of the facility was observed to be in good repair. Bathrooms and showers were clean and in good repair. Hot water temperature was between 112' and 118' F. Facility was maintained at a comfortable temperature. Required amounts of stored and perishable foods were present. Bedrooms were observed to be in good repair and bedding, storage and lighting were adequate. Medication, chemicals and toxins were appropriately under lock and key. Smoke detectors were present. Facility is equipped with a fire sprinkler system and a central pull fire alarm. Fire extinguishers were fully charged and ready for emergency use. First aid kit was fully stocked for use. Facility license was openly posted for viewing. Administrator certificate for Jessee Plenos was observed to be current and expires 8/1/2024. Three staff and 5 residents records were reviewed. Facility has 9 ambulatory residents and this accounting is within fire clearance allowances.

A review of staff records on 3/28/23 indicates that all facility staff and other individuals who require caregiver background checks have received criminal record clearances.

As a result of this visit, there were no deficiencies.

Exit interview conducted.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 03/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/28/2023
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