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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804146
Report Date: 11/14/2024
Date Signed: 11/14/2024 05:05:14 PM

Document Has Been Signed on 11/14/2024 05:05 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:TERRA LINDA RESIDENTIAL CAREFACILITY NUMBER:
496804146
ADMINISTRATOR/
DIRECTOR:		LAILANI CENZONFACILITY TYPE:
740
ADDRESS:625 TERRA LINDA COURTTELEPHONE:
(707) 542-9653
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY: 6CENSUS: 5DATE:
11/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:35 PM
MET WITH:Lailani Cenzon-AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:15 PM
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Licensing Program Analyst (LPA) Alviso conducted a Required- 1 Year visit, on 11/14/24 at approximately 1:35pm, and was greeted by caregiver Isabel. There are currently six (6) residents in care; Currently there are two (2) residents on hospice care. Administrator arrived to meet with the LPA.

There is an approved hospice waiver for three (3) residents. Facility has an infection control plan as required. Facility has an emergency disaster plan as required. Facility has an approved dementia plan of operation.
Facility has a fire clearance approval for a total of six (6) non-ambulatory residents. The facility's last fire drill was held in October, and the evacuation drill is scheduled for 2024. Facility does have a generator for emergencies if needed. The facility does have emergency food and supplies to meet the "72 hour shelter in place" requirements.

LPA reviewed five (5) resident files; All resident files were found to be complete. Medications were observed, and reviewed, including PRN medication records.
LPA reviewed five (5) staff files. LPA reviewed staff training. All five(5) staff have criminal record clearance, and are associated as required. All staff had required training. All staff had current First Aid and CPR Certification.

LPA observed sufficient supply of food, perishable and non-perishable, for resident meals/snacks. Facility had sufficient furnishings for residents in care. The facility has sufficient lighting in all rooms, bathrooms, and common areas, including night lights. There was a sufficient supply of hygiene products, cleaning supplies, and paper products for use as needed.Facility has a sufficient supply of personal protective equipment (PPE). All medications were stored/locked and inaccessible to residents in care. All cleaners/disinfectants were locked up inside the facility, and inaccessible to residents in care.
Continued on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2024
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: TERRA LINDA RESIDENTIAL CARE
FACILITY NUMBER: 496804146
VISIT DATE: 11/14/2024
NARRATIVE
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 All bathrooms had grab bars, and non-slip mat/flooring for bathing/showering as needed; Two resident rooms have access to a bathroom, with shower stall, that is right outside of their rooms. Three resident rooms have a private half bath, and one resident room has a full bathroom. There is a full bathroom in the long hallway for resident use as needed.

LPA is requesting the following documents be updated and submitted by 12/14/24:
LIC308 - Designation of Administrator Responsibility
LIC500 - Personnel Report
LIC610E-Emergency Disaster Plan (ensure to review and update as needed/required)
Copy of LIC400 Handling of Client Cash Resources (include copy of surety bond if handling cash)
Copy of Current Liability Insurance
Resident Roster

The following deficiency was observed: LPA toured the facility property with the LPA and observed a large storage shed in the yard that had an accordion style door, it was broken and hanging on one side; The shed stored miscellaneous items, including disinfectants/cleaners. Administrator stated they would be fixing this storage door. The Administrator did have a lock on the door, but this was not sufficient security with the door being broken. LPA obtained photos. This deficiency will be cited, 87705 (f)(2)- Care of Persons with Dementia-The following shall be stored inaccessible to residents with dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants, see LIC809D.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Appeal rights given to the Administrator.
Exit interview conducted with Licensee/Administrator Lailani Cenzon.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/14/2024 05:05 PM - It Cannot Be Edited


Created By: Dina Alviso On 11/14/2024 at 03:34 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: TERRA LINDA RESIDENTIAL CARE
FACILITY NUMBER: 496804146

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(f)(2)
87705 (f)(2)- Care of Persons with Dementia-The following shall be stored inaccessible to residents with dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observations, a large storage shed in the yard that had an accordion style door, was broken and hanging on one side; The shed stored miscellaneous items, including disinfectants/cleaners. Administrator stated they would be fixing this storage door. The Administrator did have a lock on the door, but this was not sufficient security with the door being broken. LPA obtained photos, the licensee did not comply with the section cited above in which poses/posed a potential risk to health, safety and/or risk of residents personal rights.
POC Due Date: 12/05/2024
Plan of Correction
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Licensee/Administrator to ensure the storage shed door is replaced in order to securely lock all items such as disinfectants/cleaners/tools to ensure they are inaccessible to residents in care. Submit how the correction was completed, and include picture(s).POC due 12/05/24.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 11/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2024


LIC809 (FAS) - (06/04)
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