Clover Home

Type of visit: Case Management - Legal/Non-compliance

On 08/14/2026, a Non-Compliance Conference was conducted in the Santa Rosa Regional Office. Present in the meeting were Regional Manager Carla Nuti-Martinez, Licensing Program Manager (LPM), Kimberley Mota, Licensing Program Analyst (LPA) Jill Nakagawa, Licensee, Jesse Plenos and Victoria Young, Applicant Umesh Pandey(via Teams) and Administrator Charlotte Lewis. The purpose of the meeting was to discuss areas of non-compliance observed and ongoing concerns of the operation of Clover Home. The Licensee was informed that this Non-Compliance Conference is a part of the Administrative Action process and due to continuing citations and areas of concern the facility will be placed on a formal Non-Compliance Plan. Also discussed was applicant's non-compliance conference held on 7/21/2026 with the Sacramento South Regional office regarding concerns of similar nature for the applicants facility Lakewood Villa Care Center #342701553. Items addressed in today's meeting include but are not limited to the following areas of concern: Criminal record clearances and need for fingerprint clearances and associations of staff. Care and Supervision Maintenance and Operations Medication Management Health and Safety Food Service Elopement Procedures Reporting requirements of incidents not reported in a timely manner Administrator Qualifications and Duties Deficiencies cited. See 809-D. (Continued on 809-C) On 8/7/26, Resident (R1) was able to leave the facility unassisted. Staff attempted to redirect R1 who was then able to leave on foot while wearing socks and temperatures approximately 102 degrees. S1 followed R1 briefly and then returned to the facility stating "it is too hot". LPA requested facility contact Woodland Police to search for R1 who was found by police and returned to the facility. During the conference it was discussed the facility had undergone a bathroom remode lwithout notification to Community Care Licensing (CCL). Applicant informed CCL during the non-compliance conference that the renovations took no more than 1 week. It was confirmed the remodel was completed on 8/7/2026. LPA observed renovations during visit on 7/21/2026. Facility was informed that building changes must be reported in advance, including resident impacts and and plans to comply with Regulation 87307(b). Per discussion, applicant appointed Charlotte Lewis as the Administrator. Although acting as the Administrator, Ms. Lewis's Administrator Certificate Expired 8/8/26. Ms. Lewis stated that paperwork was submitted to the Administrator Renewal unit in February, 2026, there is no documentation of it being received. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Exit interview was conducted with Administrative Assistant and a copy of this report was given. An immediate civil penalty is being assessed today in the amount of $500.00 due to a repeat violation for regulation 87705(b)(2).the state’s words, verbatim · CDSS document, Aug 14, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(b)(2) · Plan of correction due date: Aug 14, 2026

87705(b)(2)Care of Persons with Dementia - Safety measures to address behaviors such as wandering. This requirement is not met as evidenced by:* **Based on observations of LPA on 8/7/2026, Resident R1 eloped from facility without continued staff supervision; the facility failed to take adequate safety measures to address behaviors such as wandering for resident R1 which poses an immediate Health, Safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 14, 2026

Plan of correction: Licensee/applicant agrees to ensure elopement plan is followed. Licensee/applicant to conduct staff training regarding elopment and wandering behaviors. Proof of training with participants signature, trainer, & date of training; and elopement plan training dates to be submitted to CCL by 8/17/2026. **An immediate repeat civil penalty in the amount of $500 is assesed.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87307(b) · Plan of correction due date: Aug 14, 2026

87307 Personal Accommodations and Services (b) Toilets and bathrooms shall be conveniently located. The licensed capacity shall be established based on Section 87158, Capacity, and the following: (1) At least one toilet and washbasin for each six (6) persons.. This requirement is not met as evidenced by:Based on LPA's observations,there was only one bathroom in service for 8 residents, not 6, which is stated in regulation which poses a potential risk to the residents in care.the state’s words, verbatim · CDSS document, Aug 14, 2026

Plan of correction: Licensee to self- verify that there is at least one bathroom per 6 residents and send LPA notification by 8/17/2026.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(b) · Plan of correction due date: Aug 17, 2026

87405 Administrator - Qualifications and Duties (b)The administrator of a facility or facilities shall have the responsibility and authority to carry out the policies of the licensee.This requirement was not met as evidenced by: the list of Administrator Certification List, S1 was not found on the Current or pending list of administrators, which is a potential risk to the residents in care.the state’s words, verbatim · CDSS document, Aug 14, 2026

Plan of correction: Licensee to ensure that there is a certified Administrator to submit proof of renewal submission or facility to submit change of Administrator within 10 days. Licensee/applicant to submit proof to CCL by POC date 8/18/26.

Allegation investigated: Staff are ensuring that there is an adequate supply of food at the home. Staff are not documenting medication properly.

Licensing Program Analyst (LPA)Jill Nakagawa arrived unannounced to conduct a complaint investigation and deliver findings. Administrator Charlotte Lewis was not on site and unavailable via phone. LPA contacted Jesse Plenos, LIcensee and discussed findings. Report was signed by carestaff. The complaint alleges that Staff are not documenting medication properly. The RP states that the majority of staff do not consistently fill out the medication administration logs. LPA reviewed the medication administration records (MAR) for the month of August, 2026 and found that staff failed to mark the MAR on 8/2/2026 for resident R3 for a refusal or mark in the remarks section. MAR's for June and July and training records were unavailable for review. Based on the review of the August MAR the allegation that Staff are not documenting medication properly is Substantiated. the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6,Chapter 8), are being cited on the attached LIC 9099D. (Continued on 9099-C) Substantiated (Continued from 9099) Based on the review of the August MAR the allegation that Staff are not documenting medication properly is Substantiated and the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8, are being cited on the attached LIC 9099D. The complaint alleges that Staff are not ensuring that there is an adequate supply of food at the home. The RP states the home frequently lacks adequate food to prepare meals for residents. LPA conducted an inspection of the facility on 8/7/2026 and found that there was not an adequate supply of nonperishable food on site. LPA interviewed 2 individuals who stated that the supply of food was not consistent. Based on the observations of LPA and the interviews of individuals the allegation that there is not an adequate supply of food at the home is substantiated, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations,Title 22, Division 6 & Chapter, are being cited on the attached LIC 9099D. (Continued from 9099-A) LPA interviewed R1, R2 and R2’s responsible party (I1). 3 of 3 individuals stated that the staff were not rough with them, nor were R1 and R2 left soiled for extended periods of time. LPA also observed staff with residents during care and transfers and did not witness any rough handling or treatment. Staff used two-person assists when transferring resident from wheelchair to chair and hygiene care was provided. Based on interviews with residents in care and/or their responsible parties and LPA’s observations the allegations that Staff are handling residents in a rough manner and Staff are leaving residents soiled for an extended amount of time are unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are unsubstantiated. The complaint alleges that Staff did not administer medication as prescribed. The RP states that staff have been crushing residents’ medications. LPA interviewed 4 of 8 residents. 4 of 4 residents stated they did not receive any crushed medications. LPA also interviewed 3 staff members who give medications. 3 of 3 staff members stated that they do not crush medications unless ordered. A review of medication orders shows that there are currently no orders for crushed medications. In addition, LPA did not observe any devices or mortar and pestles for the purpose of crushing medications. Based on the review of the medication orders and the interviews with staff and residents the allegation that Staff did not administer medications as prescribed is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.the state’s words, verbatim · CDSS document, Aug 7, 2026 · control 21-AS-20260529145843

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(6) · Plan of correction due date: Aug 7, 2026

The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes items listed as per Title 22 regs.This requirement is not met as evidenced by: ***Based on observation & file review, licensee failed to maintained a complete CSMR for 1 of ***Based on observation & file review, licensee failed to maintain a complete and accurate MAR for one of 10 residents in care,which poses a potential health, safety risk for residents in care.the state’s words, verbatim · CDSS document, Aug 7, 2026

Plan of correction: Licensee to ensure that all medications are properly logged in MARS and CSMR and medication is available for verification by LPA at the time of the visit. Administrator to review all residents medications to ensure it is properly logged on CSMR and MAR is accurate and submit an LIC9098 self certification of correction to CCL by POC date of 8/14/2026.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(26) · Plan of correction due date: Aug 7, 2026

87555 General Food Service Requirements (b) The following food service requirements shall apply:(26)Supplies of nonperishable foods for a minimum of one week.. perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by: Based on LPA's observation Licensee failed to ensure that there were adequate perishable and non-perishable foods available for the required time frame for a minimum of 8 residents.the state’s words, verbatim · CDSS document, Aug 7, 2026

Plan of correction: Adminstrator to submit proof of purchase of food by 8/9/2026 to LPA to ensure adequate food supply is on site of facility.

Allegation investigated: Staff are locking residents in the facility. Staff are not providing comfortable accommodations for residents in care. Staff do not prevent vulnerable residents from leaving the facility without care, supervision or assistance.

Licensing Program Analyst (LPA) Nakagawa arrived unannounced to conduct an investigation and deliver findings regarding the above allegations. There were 8 residents and 3 staff at the time of visit. LPA met with Charlotte Lewis, the acting Administrator. The complaint alleges that Staff are locking residents in the facility. The complainant states that R1complained that staff locked them in after another resident eloped. LPA inspected the facility on two separate occasions (04/09/2026, 07/14/2026) and found no internal locks on doors that required keys. All doors leading to the exterior of facility were unlocked or able to be unlocked without a key for residents to safely evacuate the building. There are five residents who are independent. LPA was able to interview 4 of those residents and asked if they were able to leave the building unattended; 4 of 4 said they are able to do so. (Continued on 9099-C) Unsubstantiated (Continued from 9099) ***THIS PAGE OF REPORT HAS BEEN AMENDED*** Based on the interviews of residents and LPA’s observations the allegation that staff are locking residents in the facility is Unsubstantiated. Although the allegation may have occurred there is not a preponderance of evidence therefore the allegation is Unsubstantiated. The complaint alleges that Staff are not providing comfortable accommodations to residents in care. The complainant states that staff recently placed a second resident in a now shared room and positioned the second bed in front of the sliding glass door. LPA inspected all bedrooms in the facility and found there were no beds in front of a sliding glass door obstructing the exit and that required furniture was present. The facility has a fire clearance and is licensed for two beds for each of the bedrooms. The resident (R1) living in the room under investigation was not paying for a private room and therefore the addition of a roommate would have been allowed under the lease agreement. Based on the fire clearance, the lease agreement and observations the allegation that Staff are not providing comfortable accommodations to residents in care is unsubstantiated. Although the allegation may have occurred there is not a preponderance of evidence therefore the allegation is unsubstantiated. The complaint alleges that Staff do not prevent vulnerable residents from leaving the facility without care, supervision or assistance. The complainant states that the resident (R1) dislikes the facility and tries to leave often and has been brought back to the facility in the past by the Police. LPA reviewed police records and found that R1 made multiple 911 calls but according to police reports R1 was found to be safe within the facility. Based on review of police reports the allegation that Staff do not prevent vulnerable residents from leaving the facility without care, supervision or assistance is Unsubstantiated. Although the allegation may have occurred there is not a preponderance of evidence to to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Amended Report (Page 9099-C) was reviewed with Acting Administrator Charlotte Lewis via phone and signed by Carestaff Isabell Ruiz on 7/29/2026.the state’s words, verbatim · CDSS document, Jul 14, 2026 · control 21-AS-20260407125537

Type of visit: Office

On 06/04/2026, an informal office meeting was conducted in the Santa Rosa Regional Office. Present in the meeting were Licensing Program Manager (LPM), Kimberley Mota, Licensing Program Analyst, (LPA) Jill Nakagawa, and Licensee, Jesse Plenos and Victoria Young . The purpose of the informal office meeting was to discuss areas of non-compliance and observed ongoing Community Care Licensing (CCL) concerns of the operation of Clover Home. The Licensee was informed that this informal meeting is a part of the Administrative Action process and that further and/or repeat citations may result in a formal Non-Compliance Plan. Items addressed in today's meeting include but are not limited to the following areas of concern: Criminal record clearances and need for fingerprint clearances and associations of staff. Reporting requirements of incidents occurred at the facility were not reported to CCL. Elopements not reported to CCL. Administrator not in place and/or missing proper documentation to appoint one. Outstanding Plan of Corrections (POC's) Deficiencies cited. See 809-D. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. The Dept. received incident and outside reports that resident (R1) left the facility unattended. Staff (S1) called police for assistance in locating R1, who had been missing for at least 15 minutes. R1 was found by employee approximately 45 minutes later on Kentucky Street. Deficiency cited. See 809-D. Civil penalty issued in the amount of $500 per HSC.. The Dept. is issuing a citation for failure to report. The above incident was not reported to the Department in a timely manner. Deficiency cited. The Licensee has not placed an Administrator within the 30-Day timeframe required. Deficency cited. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.the state’s words, verbatim · CDSS document, Jun 4, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(b)(2) · Plan of correction due date: Jun 4, 2026

87705Care of Persons with Dementia(b)In addition...the plan of operation shall address the needs of residents with Dementia (b)(2)Safety measures to address behaviors...wandering, ingestion of toxic materials. This requirement is not met as evidenced by: Based on Incident and reports from outside parties that resident (R1) was allowed to go outside the facility unattended, which according to R1's physician's report is not allowed. This poses an immediate helath, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 4, 2026

Plan of correction: POC: Licensee to ensure all residents whose physician's reports require residents not to leave facility unattended are supervised. Licensee to provide proof of audit of 602's for all residents currently in facility by 6/5/2026. A civil penalty of $500 has been assessed Per Health & Safety Code 1568.0822(a)(3).

From the deficiency page — Deficiency type: Type B · Section cited: CCR87405(a) · Plan of correction due date: Jun 4, 2026

87405 Administrator-Qualifications and Duties (a)All facilities shall have a qualified and currently certified administrator. This requirement is not met as evidenced by: Based on LPA's interviews and records review, the licensee did not comply with the section cited above in that Licensee did not have a documented Administrator in place within 30 days. This poses a potential risk to health, safety or personal rights to persons in care.the state’s words, verbatim · CDSS document, Jun 4, 2026

Plan of correction: Licensee to submit documents for placement of Administrator to CCL by 6/11/2026.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Jun 4, 2026

87211 Reporting Requirements (1)A written reort shall be submitted to the licensing agency and to the person responsible for the resident within 7 days of the occurrence of any of the events specified in (A) through (D) below...This requirement is not met as evidenced by: Based on LPA's records review of facility and outside agencies the licensee failed to notify the deaprtment within 7 days of R1's elopement which poses a potential risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Jun 4, 2026

Plan of correction: LIcensee to ensure incidents are reported per regulation. Licensee agrees to review regulation 87211 and conduct training for all staff on reporting requirements. Evidence of completed training to be submitted to CCL by POC date of 6/11/2026.

Type of visit: Required - 1 Year

On 04/09/2026 Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct an 1-Yr Annual Inspection. LPA met with Program Director Joycelin Singh as the house manager/administrator had suddenly left their employ on 04/05/2026. At approximately 10:45AM, LPA reviewed the Facility's Staff Roster and found that there were staff on-site who had not yet received their background clearance and/or associated to the facility per regulation. Facility was toured both indoors and outdoors. LPA inspected the physical plant and food service. The outside of the facility was observed to be in good repair and safe for residents. The bathrooms and showers were clean but one toilet in the men's bathroom was leaking, but operational. 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. LPA will return at a later date to complete the annual inspection and complete the review of staff and resident records. The following deficiencies were observed and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. A civil penalty in the amount was assessed today for staff S1 not being properly cleared and for staff S2 not being properly associated to this facility. Exit interview conducted and appeal of rights left and emailed to Licensee. M. Ibarra signed on behalf of Joycelin Singh.the state’s words, verbatim · CDSS document, Apr 9, 2026

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Nakagawa arrived unannounced to conduct a Case Management - Other Visit and met with House Manager Anitha Maluw. The purpose of the visit is to check on the administration of the facility during the transition of License. LPA discussed the requirements for an Administrator and provided the House Manager with a list of documents required. House Manager has a current Administrator's Certificate #6077698740, exp. 9/2/27. LPA also requested an updated copy of the resident roster, the LIC500 and staff roster. LPA did a tour of the facility and found an adequate supply of perishable and non-perishable foods, as required. The temperature of the house was 75 degrees F and the water temperature was 106.4 degrees F. Bathrooms were clean and sanitary. Residents were clean and dressed appropriately. Rooms were furnished as per regulation. Common areas were clean and comfortable, and decorated for the hoildays. No citations were issued Exit interview conducted with Anitha Maluw.the state’s words, verbatim · CDSS document, Dec 11, 2025

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Jill Nakagawa arrived unannounced to conduct an 1-Yr Annual Inspection on March 21, 2025. Facility was toured both indoors 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 was108.9 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 locked and inaccessible to residents. Smoke detectors/carbon monoxide detector were present. Maintained monthly. Facility is equipped with a fire sprinkler system and a central pull fire alarm. Fire extinguishers were fully charged and ready for emergency use and last serviced on 1/10/2025. First aid kit was fully stocked for use. Facility has 7 ambulatory residents and 2 non-ambulatory residentsb which is within fire clearance allowances. A review of staff records on 3/21/2025 indicates that all facility staff who require caregiver background checks have received criminal record clearances and are current on their First Aid/CPR training. Facility to submit documentation of other employee training. There were no deficiencies cited on this visit. Exit interview conducted.the state’s words, verbatim · CDSS document, Mar 21, 2025

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Jill Nakagawa and Stefanie Mutialu arrived unannounced to conduct an 1-Yr Annual Inspection on March 13, 2024. Facility was toured both indoors and outdoors. LPAs 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 was117.2 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/carbon monoxide detector were present. Maintained monthly. Facility is equipped with a fire sprinkler system and a central pull fire alarm. Fire extinguishers were fully charged and ready for emergency use and last serviced on 1/15/2024. 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. .......... Continued on 809-C Continued from 809.... Facility has 9 ambulatory residents and 1 non-ambulatory resident which is within fire clearance allowances. A review of staff records on 3/13/24 indicates that all facility staff who require caregiver background checks have received criminal record clearances and are current on their First Aid/CPR training. Facility to submit documentation of other employee training. Other documents requested: Proof of Liability Insurance Resident Inventory Forms Completed SOC341A forms There were no deficiencies cited on this visit. Exit interview conducted.the state’s words, verbatim · CDSS document, Mar 13, 2024