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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247202427
Report Date: 03/29/2022
Date Signed: 03/29/2022 07:07:18 PM


Document Has Been Signed on 03/29/2022 07:07 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, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:TERRIE'S TLC SENIOR HOME IIFACILITY NUMBER:
247202427
ADMINISTRATOR:RHODES, THERESE ANNEFACILITY TYPE:
740
ADDRESS:1317 E BROOKDALE DR.TELEPHONE:
(209) 726-0548
CITY:MERCEDSTATE: CAZIP CODE:
95340
CAPACITY:6CENSUS: 0DATE:
03/29/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:34 PM
MET WITH:Administrator, Therese RhodesTIME COMPLETED:
02:22 PM
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On 3/28/2022 Licensing Program Analysts (LPAs) M. Garza and K. Kaur completed an unannounced case management visit. LPAs were greeted by Administrator, Therese "Terrie" Rhodes and permitted entry into facility.
At this time the facility is in the process of a remodel and does not have any residents in care and no staff working.

LPAs discussed reason for visit with Terrie. Complaint interview with Administrator was conducted and additional information was gathered. LPA's requested additional information (Physicians Report for R1, Needs and Assessment Appraisal, Admission Agreement, List of R1's medications, Death Report and all Special Incident Reports for R1).

Administrator to provide to CCL no later than Friday, April 1, 2022. Exit interview completed. No deficiencies cited at this visit.

Due to COVID precautionary measures a copy of this report will be emailed to: Rhodesbuds@yahoo.com. A delivered an read receipt serves as confirmation.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: (559) 365-9009
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2022
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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