Facility Evaluation Report, 07/19/2022 — Clover Valley Guest Home, Upper Lake CA

Licensing Program Analyst (LPA) Hansen conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and was welcome by Licensee Arlene Wing. LPA arrived at facility and had temperature checked and logged. Facility has 3 residents.

At 9:10 AM LPA toured facility with Licensee; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored in a locked cabinet in the facility laundry room and locked hallway closet. There was a supply of cleaners, hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings. Fire Extinguisher was found to be last charged on 9/18/2021 at the time of the visit. Smoke Detector was found to be operational carbon monoxide detectors were unfunctional at time of visit, licensee fixed by end of visit. Medications are kept in a locked cabinet in the office. Residents bathroom faucet water tested 116 degrees F. at time of visit falling within Title 22 Regulation range of 105 degrees F. and 120 degrees F. A technical has been issued for facility to conduct repairs in residents shower and LPA will assess at case management in a month.

Facility has submitted a mitigation program plan that has been approved and an Infection Control Plan. Posters have been placed at facility. Entrance has small table with hand sanitizer and other items designated for visitors and staff before coming into work. Facility has PPE supply stored in hall closet. All staff had masks on during this visit. All staff had PPE training required on file and have received N-95 fit testing. All staff have declined COVID vaccinations and have signed waivers on file.