Clearwater At Sonoma Hills

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff are mismanaging resident's medication and not providing it to the resident as prescribed

Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 6/25/25 at approximately 9:40am, and met with Administrator/Executive Director James Homer and Health Services Director Eadgitha Waken. Reporting party alleges "staff are mismanaging resident's medication and not providing it to the resident as prescribed". LPA reviewed resident's (R1) records, medication records, care plan, assessments, and financial records on care plan fees. LPA obtained copies of resident (R1) records as requested. LPA obtained a copy of notice of fees regarding care plan levels, and medication assistance costs, letter dated 3/31/25. The 3/31/25 letter of new fee structure for assisted living and memory support was mailed out to all resident responsible parties, per Administrator. LPA interviewed staff, S1, and S2, and other related parties. The investigation revealed that R1's medication prescribed for mood and anxiety had been changed by the Physician, dosage was changed to three pills athe state’s words, verbatim · CDSS document, Jun 25, 2025 · control 21-AS-20250602102129

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Lack of supervision resulted in resident sustaining an unwitnessed fall Staff are not assisting resident with incontinence care and/or assisting resident with a toileting schedule Staff are not ensuring resident(s) has clean clothing Staff are not assisting resident(s) with hygiene care

Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 10/3/2024 at approximately 9:00am, and met with Executive Director James Homer, and Health Services Director/LVN Janice Foster. LPA reviewed resident (R1) records, including medical documentation, and facility records. LPA conducted interviews with staff (S2, S3, S4, S5), and with other related parties. LPA obtained conflicting information regarding allegations of "lack of supervision resulted in resident sustaining an unwitnessed fall, staff are not assisting resident with incontinence care and/or assisting resident with a toileting schedule, staff are not ensuring resident(s) has clean clothing, staff are not assisting resident(s) with hygiene care". Per record reviews and interviews, the investigation revealed that R1 had a care plan in place, and the resident was on a shower schedule, and a laundry schedule. R1 would be offered their shower multiple times, and most times they could get them to shower, eventhe state’s words, verbatim · CDSS document, Oct 3, 2024 · control 21-AS-20240604084835

Allegation investigated: Residents laundry not being done due to a broken washing machine Facility did not seek timely medical

Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 10/3/2024 at approximately 9:00am, and met with Executive Director James Homer, and Health Services Director/LVN Janice Foster. LPA toured the facility, including the memory care unit; LPA reviewed resident (R1) records, including medical documentation, and reviewed facility records. LPA conducted interviews with staff (S2, S3, S4, S5, S6), and with other related parties. LPA obtained conflicting information regarding allegations of "residents laundry not being done due to a broken washing machine, and facility did not seek timely medical". Per record reviews and interviews, the investigation revealed that R1 had a care plan in place, and the resident was on a shower schedule, and a laundry schedule. Per interviews with staff (S2) the memory care machines are currently both working well. Approximately six months ago one of the machines had to have the lock lid switch replaced, when the lid closed it would lockthe state’s words, verbatim · CDSS document, Oct 3, 2024 · control 21-AS-20240917161619

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff neglect led to resident sustaining unstageable pressure injuries Staff did not rotate resident as instructed by hospice care staff Staff did not ensure resident was adequately fed Staff left resident in soiled clothing for extended periods Staff did not provide a safe environment for resident Staff handled resident in a rough manner Staff made inappropriate comment toward resident Staff mismanaged resident’s medication Staff did not ensure resident was involved in activities Staff did not provide resident’s authorized representative with resident’s records

Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 8/29/2024 at approximately 9:40am, and met with Interim Administrator Paul Gozon, and Health Services Director/LVN CA Licensed Janice Foster. LPA reviewed resident (R1) records, including medical documentation, hospice records, and facility records. LPA conducted interviews with staff (S1,S2,S3), and conducted interviews with other related parties. Per record reviews, hospice record reviews, and conducted interviews, the investigation revealed that staff stated resident was being turned/rotated as required by care plan/hospice plan. R1 was receiving hospice care services, this included care for the pressure injuries. LPA reviewed hospice progress notes regarding all visits to the facility to provide care, and there were no noted issues and/or concerns regarding staff care and/or neglect. Per record reviews, R1 moved in 4/16, and went on hospice care 5/10, resident had a care plan in place, which included a hospthe state’s words, verbatim · CDSS document, Aug 29, 2024 · control 21-AS-20240429095831

Allegation investigated: Staff force residents to take showers.

Licensing Program Analysts (LPAs), Alviso and Florio, conducted a complaint inspection, on 4/17/24 at approximately 8:40am, and met with Administrator Janna O'Sullivan, and Health Services Director Janice Foster. LPAs requested facility records, including staff and resident files. LPAs reviewed all records. LPAs interviewed staff, and other related parties regarding the allegation. The reporting party (RP) alleges "staff force residents to take showers." The investigation revealed that resident (R1) has a care plan that includes assistance with showers. Resident is on a shower schedule, but per interviews R1 refuses many times to take their showers regularly and/or as scheduled; Per interviews, staff will offer R1 their shower, and if refused, the staff will come back after a short time and ask R1 again. Staff deny forcing any residents to take a shower, per interviews. The investigation found that there was differing information obtained per records, interviews, and per information prthe state’s words, verbatim · CDSS document, Apr 17, 2024 · control 21-AS-20240301093451

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Facility staff mismanaged residents' medications. Resident's medication information was not kept confidential

Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 12/20/23 at approximately 9:30am, met with Administrator Jana O'Sullivan, and H&W Director Janice Foster. LPA reviewed resident records, R1 & R2 records, and facility records. LPA conducted interviews with staff, S1, S2, and other related parties. The investigation revealed that R1 had a prescription medication go out of the community with another resident's, R2, medications who had moved out of the facility. R2's responsible party contacted the facility regarding the medication that was not R2's that was included with R1's upon their discharge from the facility. Responsible party stated they would return R1's medication back to the facility. The facility received R1's prescription medication from the responsible party who dropped it off to them. Per record review, R1 didn't miss any medication. Resident's identification, name and medication information, was not kept confidential as required, Resident's prescrithe state’s words, verbatim · CDSS document, Dec 20, 2023 · control 21-AS-20231218152714

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Resident not allowed to use facility phone and/or receive calls Resident is not allowed visitors Resident is not allowed to leave the facility

Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 9/26/2023 at approximately 9:00am, and met with Administrator Janna O'Sullivan, H&W Director Janice Foster, and Memory Care Director Monica Hernandez. LPA reviewed resident(R1) records, and facility records. LPA conducted interviews with staff, S1, S2, S3, and conducted interviews with other related parties. The investigation revealed that per record reviews, and interviews, the resident (R1) is allowed to use the phone to make calls if wanted. There is a phone in the medical staff office that may be used by resident(s) when wanted. Administrator stated that there is a cordless phone that may be used by residents if wanted. Staff can provide the resident(s) with a phone to make a call. Staff interviewed stated that if a call comes into the facility for a resident they will notify the resident of the call so the resident may take/receive the call. Investigation revealed that R1 is allowed visitors, and the log othe state’s words, verbatim · CDSS document, Sep 26, 2023 · control 21-AS-20230919134801

Allegation investigated: Staff hit resident with an object

Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 9/26/2023 at approximately 9:00am, and met with Administrator Janna O'Sullivan, H&W Director Janice Foster, and Memory Care Director Monica Hernandez. LPA reviewed resident(R1) records. LPA reviewed two (2) staff files. LPA conducted interviews with staff, S1, S2, S3, S4, and other related parties. The investigation revealed that staff, S4, denied hitting the resident at any time, and denied hitting the resident with an obbject. R1 was assessed by the Admnistration staff after the allegation was reported, and resident was observed to have no injuries, and R1 was observed to be at their baseline. Per staff records reviewed, staff has required trainings. The investigation found that there was different information from interviews conducted, and information provided by the reporting party. There was no information obtained to support a violation had occurred regarding the allegation. Based on the interviews, recorthe state’s words, verbatim · CDSS document, Sep 26, 2023 · control 21-AS-20230925135806