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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206846
Report Date: 02/02/2022
Date Signed: 02/02/2022 02:51:10 PM

Document Has Been Signed on 02/02/2022 02:51 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:TEHACHAPI MANORFACILITY NUMBER:
157206846
ADMINISTRATOR:RODRIGUEZ, LORENAFACILITY TYPE:
740
ADDRESS:20400 OAK KNOLL DR.TELEPHONE:
(661) 822-7885
CITY:TEHACHAPISTATE: CAZIP CODE:
93561
CAPACITY: 6CENSUS: 3DATE:
02/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:24 AM
MET WITH:Administrator Lorena RodriguezTIME COMPLETED:
12:45 PM
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Licensing Program Analyst LPA Shawna Doucette conducted an Annual Inspection on this date. LPA was met by Administrator Lorena Rodriguez and discussed the purpose of the visit. LPA and Administrator Lorena Rodriguez toured the facility.

Visitor log-in/temperature check, masks, and disinfection station was observed upon entry. Facility has one entrance/exit point. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common areas. Hand washing and other various Covid-19 related signs were observed in the common areas.

LPA observed a two day supply of perishable food and seven day supply of non-perishable food. Cleaning supplies were observed locked in the laundry room. LPA observed the following personal protective equipment in the laundry room; face shields, hand sanitizer, gowns, gloves, and masks. Staff records were reviewed for infection control training. LPA observed all facility staff wearing masks.

Resident’s files have updated emergency contact information.

No deficiencies were observed.

Exit interview was conducted and a copy of this report was provided via email.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE: DATE: 02/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/02/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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