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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045920015
Report Date: 10/03/2023
Date Signed: 10/03/2023 01:23:22 PM


Document Has Been Signed on 10/03/2023 01:23 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:TEHAMA MANORFACILITY NUMBER:
045920015
ADMINISTRATOR:BRAY, DAWNFACILITY TYPE:
735
ADDRESS:65 BRENDA DRIVETELEPHONE:
(530) 838-3898
CITY:CHICOSTATE: CAZIP CODE:
95928
CAPACITY:3CENSUS: 3DATE:
10/03/2023
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Direct Care Staff- Brianna ZimmermanTIME COMPLETED:
01:25 PM
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Licensing Program Analyst (LPA) Boyles arrived at the care home today and met with the Direct Care Staff, , Brianna Zimmerman, to conduct a post licensing visit.

LPA Boyles and care staff toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, garage, backyard, and common restrooms.

LPA observed the facility to be clean, in good repair and odor-free and each bathroom to have the necessary grab bars, non-skid flooring or shower chair, paper towels, trash can with lids and 20-second hand-washing poster.

Facility has a 2-day perishable and a 7-day non-perishable amount of food and sharps to be locked.

LPA observed one (1) fire extinguishers, fire detectors, and carbon monoxide detectors. In the areas toured no immediate health, safety, or personal rights violations were observed.

No deficiencies cited for the post licensing visit.












SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Jaynae BoylesTELEPHONE: (916) 917-3040
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2023
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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