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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803047
Report Date: 12/09/2022
Date Signed: 12/09/2022 03:55:00 PM

Document Has Been Signed on 12/09/2022 03:55 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
SANTA ROSA RO, 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:
12/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Licensee, Teresita ShevickTIME COMPLETED:
04:05 PM
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Licensing Program Analyst (LPA) Victoria Bertozzi arrived unannounced to conduct an Annual Required inspection and was greeted by a caregiver. Licensee/Administrator, Teresita Shevick arrived later. The inspection is focused on the Infection Control procedures and practices of this facility

Upon arrival, LPA was screened by staff for Covid-19 which included a temperature check and signing in. LPA confirmed that facility is no longer requiring vaccination verification per recent guidance. LPA initiated a walk-through of the facility around 2:45 pm and observed the following: Facility has COVID-19 posters throughout that include hand washing signs in bathrooms. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is located throughout common areas of the facility. Staff had masks on during this visit. Commonly touched surfaces are disinfected at least once per day. Facility continues to screen staff and residents and maintains documentation.

Facility has a designated visitation area outside and is allowing for visitation in resident rooms per CCL guidance. Staff continue to receive training on infection control and donning and doffing of Personal Protective Equipment PPE but have not been N95 fit tested.

Facility has more than a 30 day supply of PPE including but not limited to masks, gowns, and hand sanitizer. Facility maintains a 30 day supply of medication. Fire extinguisher is fully charged but has not been serviced within the last year. LPA noted during the last annual inspection that the fire extinguisher had not been serviced. Per conversation with Licensee, she was told by the vendor that the fire extinguisher is supposed to be serviced every two years. Smoke Detectors and Carbon Monoxide detector were tested and operational.

Continued on LIC809C

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: TERENE MANOR
FACILITY NUMBER: 496803047
VISIT DATE: 12/09/2022
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Continued from LIC809C

Facility has submitted their Emergency Disaster Plan, Infection Control Plan and Mitigation Plan.



Licensee/Administrator to submit updates of the following documents by 1/09/2023:
LIC 308 Designated Administrator (if applicable)
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan (review and update if changes)
Liability Insurance


No deficiencies cited during this inspection.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2022
LIC809 (FAS) - (06/04)
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