577004529-8-7-2026-21-AS-CMAZ-DXJVEF-20260902162215

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 577004529
Report Date: 08/07/2026
Date Signed: 08/07/2026 07:14:21 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/29/2026 and conducted by Evaluator Jill Nakagawa

COMPLAINT CONTROL NUMBER: 21-AS-20260529145843

FACILITY NAME:	CLOVER HOME		FACILITY NUMBER:	577004529
ADMINISTRATOR:	PLENOS, JESSE		FACILITY TYPE:	740
ADDRESS:	412 CLOVER STREET		TELEPHONE:	(530) 402-1029
CITY:	WOODLAND	STATE: CA	ZIP CODE:	95695
CAPACITY:	14	CENSUS: 8	DATE:	08/07/2026
		UNANNOUNCED	TIME BEGAN:	02:45 PM
MET WITH:	Jesse Plenos, Licensee via phone		TIME COMPLETED:	07:15 PM

ALLEGATION(S):

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

INVESTIGATION FINDINGS:

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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

Estimated Days of Completion:

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 5

Control Number 21-AS-20260529145843

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: CLOVER HOME	FACILITY NUMBER: 577004529
	VISIT DATE: 08/07/2026

NARRATIVE

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(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.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 21-AS-20260529145843

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: CLOVER HOME	FACILITY NUMBER: 577004529
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/07/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/07/2026 Section Cited CCR 87465(h)(6)	1 2 3 4 5 6 7	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	1 2 3 4 5 6 7	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.
	8 9 10 11 12 13 14	***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.	8 9 10 11 12 13 14
Type B 08/07/2026 Section Cited CCR 87555(b)(26)	1 2 3 4 5 6 7	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:	1 2 3 4 5 6 7	Adminstrator to submit proof of purchase of food by 8/9/2026 to LPA to ensure adequate food supply is on site of facility.
	8 9 10 11 12 13 14	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.	8 9 10 11 12 13 14

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/29/2026 and conducted by Evaluator Jill Nakagawa

COMPLAINT CONTROL NUMBER: 21-AS-20260529145843

FACILITY NAME:	CLOVER HOME		FACILITY NUMBER:	577004529
ADMINISTRATOR:	PLENOS, JESSE		FACILITY TYPE:	740
ADDRESS:	412 CLOVER STREET		TELEPHONE:	(530) 402-1029
CITY:	WOODLAND	STATE:CA	ZIP CODE:	95695
CAPACITY:	14	CENSUS: 8	DATE:	08/07/2026
		UNANNOUNCED	TIME BEGAN:	02:45 PM
MET WITH:	Jesse Plenos via phone		TIME COMPLETED:	07:15 PM

ALLEGATION(S):

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Staff are leaving residents soiled for an extended amount of time.
Staff did not administer medication as prescribed.
Staff are handling residents in a rough manner.

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 21-AS-20260529145843

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: CLOVER HOME	FACILITY NUMBER: 577004529
	VISIT DATE: 08/07/2026

NARRATIVE

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(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.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2026

LIC9099 (FAS) - (06/04)

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