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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206846
Report Date: 01/23/2023
Date Signed: 01/23/2023 01:18:06 PM

Document Has Been Signed on 01/23/2023 01:18 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: 4DATE:
01/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Licensee Lorena RodriguezTIME COMPLETED:
01:30 PM
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On 01/23/23, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection - Infection Control. LPA introduced self, stated the purpose of the visit, and met with Alejandra Gaitan Perez. LPA was granted entry into the facility. Two residents were present upon arrival. Licensee Lorena Rodriguez was called and arrived shortly with two residents. All four residents were present during the inspection.

Upon entry facility staff was observed with no facial covering. Visitor log-in/temperature check was observed upon entry. Hand sanitizer was readily available to residents and visitors. Facility has one entrance/exit point. Facility appeared cleaned with no obstruction or fire clearance issues. Social distancing is maintained in the common and dining areas. COVID-19 related signs and cough etiquette postings observed.

LPA checked residents’ locked medications. 30-day PPE supplies observed. Food supply was checked and appeared to be an adequate supply. Cleaning supplies were stored and locked in cabinet in medication room. LPA observed fire extinguisher served date: 01/17/23. All resident’s room toured and observed to be adequately furnished and lit. LPA observed 4 single occupant room. Bathrooms are observed with securely fastened grab bars and non-skid mat. LPA observed bathrooms trash bin with lid. Hand washing posting not observed by bathroom sinks. The exterior tour was conducted. Outside observed free of debris. Staff records were reviewed for good health and infection control training. All five resident records reviewed to have updated emergency contact information.

No deficiencies issued during this inspection.

Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 1/30/23. The following updated forms were requested: Lic 308, Lic 309 (if applicable), Lic 500, Lic 610E, Lic 9282, control of property, current Administrator Certificate, and current liability insurance. A copy of this report was provided to Licensee.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 01/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/23/2023
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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