Health inspection·January 9, 2025

F 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure residents' rooms measured at least 80 square (sq) feet (ft) per resident in 14 (room [ROOM NUMBER], room [ROOM NUMBER]. Rooms 7 through 14, and Rooms 19 through 22) of 22 resident rooms in the facility. Findings included: The Client Accommodations Analysis, dated 01/08/2025, revealed the facility had 14 rooms (Rooms 1-2, 7-14, and 19-22) with an approved capacity of four beds that each measured 307.8 sq ft, which yielded a total 76.95 sq ft for reach resident. On 01/08/2025 at 10:02 AM, the Maintenance Supervisor measured the following rooms and confirmed the following dimensions: - In room [ROOM NUMBER], there was 76.95 sq ft for each resident. - In room [ROOM NUMBER], there was 76.95 sq ft for each resident. - In room [ROOM NUMBER], there was 76.95 sq ft for each resident. - In room [ROOM NUMBER], there was 76.95 sq ft for each resident. - In room [ROOM NUMBER], there was 76.95 sq ft for each resident. - In room [ROOM NUMBER], there was 76.95 sq ft for each resident. - In room [ROOM NUMBER], there was 76.95 sq ft for each resident. - In room [ROOM NUMBER], there was 76.95 sq ft for each resident. - In room [ROOM NUMBER], there was 76.95 sq ft for each resident. - In room [ROOM NUMBER], there was 76.95 sq ft for each resident. - In room [ROOM NUMBER], there was 76.95 sq ft for each resident. - In room [ROOM NUMBER], there was 76.95 sq ft for each resident. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 055756 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055756 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cloverdale Healthcare Center 300 Cherry Creek Rd Cloverdale, CA 95425 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)