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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 176801307
Report Date: 03/07/2024
Date Signed: 03/07/2024 01:40:09 PM

Document Has Been Signed on 03/07/2024 01:40 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:MANZANITA HOUSEFACILITY NUMBER:
176801307
ADMINISTRATOR:MARIAH UDENFACILITY TYPE:
735
ADDRESS:3997 MANZANITA DRIVETELEPHONE:
(707) 274-9293
CITY:NICESTATE: CAZIP CODE:
95464
CAPACITY: 6CENSUS: 5DATE:
03/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Mariah Uden, AdministratorTIME COMPLETED:
01:50 PM
NARRATIVE
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License Program Analyst (LPA) Hansen arrived unannounced to conduct an annual inspection visit of the facility. LPA was welcomed by Licensee/Administrator, Mariah L. Uden. There are 5 clients at facility.

At approximately 9:30 AM, LPA toured the building and grounds which was found to be clean and in good repair, LPA observed all walkways and exits to be unobstructed. The amount of fresh and non-perishable foods was within regulation. Toxins are secured in locked laundry room cabinets, not accessible to clients. Medication is centrally stored and secured in the office. There is a sufficient supply of hygiene products and linens on hand for client use. Water temperature measured 113.9 degrees F, within regulation between 105 and 120 degrees F at faucets accessible to clients. 2 Fire extinguishers viewed were charged and last inspected 02/01/2024. Smoke detectors and Carbon Monoxide detectors were tested and found to be in working order. Facility has pull station for fire alarm. Disaster Drills are conducted quarterly with the last being a fire drill conducted on 02/01/2024.

LPA reviewed 5 out of 5 Client records and 4 of 4 Staff records. At approximately 10:20AM, LPA reviewed 5 of 5 Client records. 5 of 5 client files have current Appraisals and contain completed admission agreements.
At approximately 11:45AM, LPA reviewed 4 of 4 Staff records, which contained the required documentation; although staff (S1) did not have TB test results (see LIC.809-D) First aid and CPR certification were current in staff files reviewed.

The Medications of 2 out of 2 clients were found to be given according to physicians’ directions on 3/7/2024 at approximately 1:00 PM. Centrally Stored Medication Record (CSMR) of 2 out of 2 residents were found to be complete and accurate. Facility does not handle P&I monies. Administrator's Certificate for Maria Uden expired on 07/30/2023 and new certificate is pending.
Continue on LIC809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/07/2024
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 03/07/2024 01:40 PM - It Cannot Be Edited


Created By: Shannan Hansen On 03/07/2024 at 01:15 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: MANZANITA HOUSE
FACILITY NUMBER: 176801307

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 4 staff did not have Tuberculosis test/results documentation, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/28/2024
Plan of Correction
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Facility will update staff (S1) files to meet regulation 80066 (a)(11) no later than POC due date, 3/28/2028 and submit copy of TB documentation as proof to clear.
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:Shannan Hansen
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2024


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: 03/07/2024
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The following deficiencies were observed (see LIC 809D) and 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. Exit interview conducted and appeal of rights provided..

LPA Hansen is requesting Licensee to update the following documents by 3/28/2024:

LIC500 Personnel Report
LIC610D- Disaster Plan (if changes)
LIC 9020 Register of Facility Client’s

Copy of Control of Property - Lease

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

DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
LIC809 (FAS) - (06/04)
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