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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 176801307
Report Date: 03/08/2022
Date Signed: 03/08/2022 11:01:03 AM

Document Has Been Signed on 03/08/2022 11:01 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:MANZANITA HOUSEFACILITY NUMBER:
176801307
ADMINISTRATOR:VEDA CHESTERFACILITY TYPE:
735
ADDRESS:3997 MANZANITA DRIVETELEPHONE:
7072749293
CITY:NICESTATE: CAZIP CODE:
95464
CAPACITY: 6CENSUS: 5DATE:
03/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Mariah Uden - Administrator TIME COMPLETED:
11:00 AM
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At approximately 09:25 AM, Licensing Program Analyst (LPA) Shannan Hansen arrived at this facility, unannounced, to conduct an Annual Required Infection Control inspection. LPA met with Administrator Mariah Uden. There are 4 Clients at the facility at this time and 5 enrolled.

LPA arrived at the facility and was asked health screening questions and had temperature checked. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers were found to be charged and inspected last on 4/22/2021. Smoke Detectors & Carbon monoxide detector was found to be operational during the visit. The supply of both perishable and nonperishable foods was within Title 22 Regulations. Food was properly stored to prevent contamination. Hot water temperature measured between 115.5 degrees F and 116.2 degrees F which is within acceptable regulations of 105 to 120 degrees F in client’s bathroom faucets. Toxins were secure and not accessible, kept locked in laundry room cabinets. There was a supply of cleaners, hygiene products and paper products available for client use.

Facility has submitted a Covid Mitigation plan which was approved on 5/18/2021. Posters are in place at the entrance and throughout the home. The entrance area does not have space to conduct a health screening, so it is done in the dining room/ kitchen area. Facility has stored PPE supplies in kitchen, laundry room, and back bathroom. Medications are secure and not accessible to clients in locked staff office. Facility has a 30-day supply of medication for clients. Clients do not typically wear masks inside the facility but have them available. Clients do however, wear masks while away from the facility. All staff had masks on during this visit.


Continued LIC809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 03/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/08/2022
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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: MANZANITA HOUSE
FACILITY NUMBER: 176801307
VISIT DATE: 03/08/2022
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Infection Control:

In addition,facility has a designated area for visitors. Clients are able to use the “client” house phone for facetime and telephone calls when contacting family members and others, as well many of the clients have their own phones. Staff had PPE training required but still need to get N-95 fit testing, administrator is working on this.



LPA reviewed Licensing Information System (LIS) with administrator who stated the previous Director/Administrator passed away 3 years ago and needs to be taken off of the LIS form. In addition, LPA advised facility to contact Local County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility.

LPA was shown current copies of 1st Aid and CPR Certificates

There were no deficiencies found in the areas inspected.

No citations issued

LPA is requesting the following documents to be submitted to CCL in order to update facility file by 03/31/2022:

LIC 308 Designated

LIC 500 Personnel Summary

LIC 400 Affidavit Regarding Resident Cash Resources

LIC 402 Surety Bond

LIC 610 Emergency Disaster Plan

LIC 9020 Register of Facility Client’s/Resident’s

Copy of Current Administrator's qualifications and Certificate

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2022
LIC809 (FAS) - (06/04)
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