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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803047
Report Date: 09/23/2025
Date Signed: 09/23/2025 01:31:52 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/24/2025 and conducted by Evaluator Robert Frank
COMPLAINT CONTROL NUMBER: 21-AS-20250624091321
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:
09/23/2025
UNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Teresita Shevick, AdministratorTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Staff emotionally abuses residents while in care.

Staff verbally abuses residents while in care.

Residents are not accorded dignity in their personal relationship with staff.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Robert Frank arrived unannounced to deliver findings regarding the above allegations and met with facility Administrator Teresita Shevick.

During the investigation LPA interviewed four (4) staff members, five (5) residents, reviewed files and took photographs of parts of the facility.

Staff emotionally abuse residents in care Staff verbally abuse residents in care, Residents are not accorded dignity in their personal relationship with staff. Complaint alleges that an identified staff does not accord dignity in their relationships with residents by emotionally and verbally abusing residents in care by speaking to them disrespectfully, making them feel like they are burdens and frequently arguing with them. During resident interviews, LPA asked how staff treated residents.

Continued on 9099-C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Robert Frank
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 21-AS-20250624091321
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/23/2025
NARRATIVE
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...Continued from 9099

Resident responded stating that, “I never get anything positive, just negative feedback. It’s hard to take when you can’t take care of yourself” and that staff “like to push the weak down” adding that the identified staff has favorites, is mean to them and is always on their case. Resident reported that they “have basically stopped talking as I just don’t want to deal with it”. “It” being in reference to being treated negatively. Another resident interviewed reported that a resident stated that a staff member yelled at them and other residents. They stated, “we would have yelling matches”. When asked to elaborate, the resident stated, “we used to battle.” When asked if the facility provides snacks a resident said, “I am afraid to ask for snacks, I don’t want to get yelled at.” Resident stated, “I need to be careful when I open my mouth”. Based on LPA’s interviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 Chapter 8, are being cited on the attached 9099D.

Exit interview conducted. Copy LIC-9099, LIC-9099C, LIC-9099D, Plan of Corrections and Appeal Rights discussed and provided to Administrator Shevick. Signature on form confirms receipt of documents.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Robert Frank
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20250624091321
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/23/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/14/2025
Section Cited
CCR
87468.1(a)(1)
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87468.1Personal Rights of Residents in All Facilities(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by:
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Licensee to schedule training with an approved outside vendor or Long Term Ombudsmen for all care staff regarding personal rights of residents. Licensee to provide scheduled training date to Community Care Licensing (CCL) by due date of 10/1/2025.
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Based on observation and interviews, the licensee did not comply with the section cited above in that two (2) out of five (5) residents reported incidents of verbal and emotional abuse which poses a potential health, safety or personal rights risk to persons in care.
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 Proof of training must include Staff Names and Signatures. Proof of training to be submitted to CCL by POC due date of 10/14/2025.
Type B
10/14/2025
Section Cited
CCR
87468.1(a)(3)
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87468.1Personal Rights of Residents in All Facilities(a)Residents in all residential care facilities...the following personal rights:(3)To be free from punishment, humiliation, intimidation, abuse, or other actions...such as... interfering with daily living functions such as eating, sleeping, or elimination.
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Licensee to schedule training with an approved outside vendor or Long Term Ombudsmen for all care staff regarding personal rights of residents. Licensee to provide scheduled training date to Community Care Licensing (CCL) by due date of 10/1/2025.
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This requirement is not met as evidenced by:Based on observation and interviews, the licensee did not comply with the section cited above in that two (2) out of five (5) residents reported incidents of verbal and emotional abuse which poses a potential health, safety or personal rights risk to persons in care.
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 Proof of training must include Staff Names and Signatures. Proof of training to be submitted to CCL by POC due date of 10/14/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Robert Frank
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3