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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803047
Report Date: 02/04/2022
Date Signed: 02/04/2022 11:33:38 AM

Document Has Been Signed on 02/04/2022 11:33 AM - 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:TERENE MANORFACILITY NUMBER:
496803047
ADMINISTRATOR:SHEVICK, TERESITAFACILITY TYPE:
740
ADDRESS:120 SAVANNAH WAYTELEPHONE:
(707) 837-9915
CITY:WINDSORSTATE: CAZIP CODE:
95492
CAPACITY: 6CENSUS: 5DATE:
02/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Licensee, Teresita ShevickTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Victoria Willis arrived unannounced to conduct an Annual Required inspection and met with Licensee, Teresita Shevick. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival, LPA observed that facility has a sign in sheet for visitors and their temperature is documented. LPA conducted a walk-through of the facility and observed that all exits were free from obstructions. Covid-19 posters were posted throughout the facility that included hand-washing signs in each bathroom. Hand sanitizer was observed in common areas and are located in resident rooms. Facility has PPE stations outside of isolation rooms. Facility staff have completed PPE training and have been N-95 Fit tested. Facility screens residents once a day and staff daily for Covid-19 symptoms and results are documented. LPA confirmed that facility is following the staff vaccination guidance per PIN 21-44-ASC. Residents are encouraged to wear masks while in the community and staff are required to wear masks while in the facility. All staff had masks on during this visit. Facility disinfects commonly touched services daily and after each use.

Facility has a designated visitation area outside and is following current visitation guidelines.

Facility has submitted a Covid Mitigation Plan that has been reviewed by CCL. LPA observed at least 30 days of PPE including gloves, face shields, masks and gowns.

LPA and Licensee discussed facility's Emergency Disaster Plan. Fire extinguisher was charged but has not been serviced within the last year. Due to residents in isolation, LPA was unable to test smoke alarms but Licensee agrees to have fire system checked.

No deficiencies cited during this inspection.

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Willis
LICENSING EVALUATOR SIGNATURE: DATE: 02/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/04/2022
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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