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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045920015
Report Date: 04/25/2024
Date Signed: 04/25/2024 10:15:36 AM

Document Has Been Signed on 04/25/2024 10:15 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:TEHAMA MANORFACILITY NUMBER:
045920015
ADMINISTRATOR/
DIRECTOR:		BRAY, DAWNFACILITY TYPE:
735
ADDRESS:65 BRENDA DRIVETELEPHONE:
(530) 838-3898
CITY:CHICOSTATE: CAZIP CODE:
95928
CAPACITY: 3CENSUS: 3DATE:
04/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:25 AM
MET WITH:Adminstrator- Renne Rhodes TIME VISIT/
INSPECTION COMPLETED:
10:30 AM
NARRATIVE
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On 04/24/2023, Licensing Program Analyst (LPA) Jaynae Boyles, arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPA met with Facility Administrator, Renne Rhodes and explained the purpose of the visit.

LPA Boyles and Administrator 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, shed, and common restrooms.

LPA observed each resident bedroom to have the required furnishings, working lights and windows with screens. LPA observed toxic chemicals and medications to be locked and inaccessible to residents. LPA observed each bathroom to have the necessary grab bars, non-skid flooring, 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. Hot water temperature was measured above the regulation temperature in three locations in the facility.

LPA observed two (2) fire extinguishers, fire detectors, and carbon monoxide detectors. LPA observed a complete emergency disaster plan and emergency disaster drills conducted within the last 12 months. LPA observed a first aid kit complete and ready for emergency use.

In the areas toured no immediate health, safety, or personal rights violations were observed. LPA observed the facility to be clean, in good repair and odor-free.

LPA reviewed a total of three (3) residents' files and three (3) staff files which contained all the required documentation.

Several topics were discussed.

Deficiencies cited from Title 22 Regulations and or the California Health and Safety Code.



An exit interview was conducted, and Plans of Corrections were reviewed and developed collaboratively. A
copy of this report, LIC 809-D, and Appeal Rights were discussed and provided.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Jaynae Boyles
LICENSING EVALUATOR SIGNATURE: DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2024
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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Document Has Been Signed on 04/25/2024 10:15 AM - It Cannot Be Edited


Created By: Jaynae Boyles On 04/25/2024 at 10:05 AM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: TEHAMA MANOR
FACILITY NUMBER: 045920015

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in three locations in the facility water was measured above 120 degrees F which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/02/2024
Plan of Correction
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Admin will measure the water two times a week for four weeks to ensure that the water at the facility remains in compliance. Admin will provide training to the staff to inform of the importance of ensuring the water is within the required range.
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:Lauren Crocker
LICENSING EVALUATOR NAME:Jaynae Boyles
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2024


LIC809 (FAS) - (06/04)
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