306005606-9-21-2021-22-AS-RQUZ-C73PWP-20210921114105

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005606
Report Date: 09/21/2021
Date Signed: 09/21/2021 11:41:10 AM

COMPREHENSIVE INSPECTION

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	TERANIMAR HOMECARE		FACILITY NUMBER:	306005606
ADMINISTRATOR:	EVELYN DELA CRUZ		FACILITY TYPE:	740
ADDRESS:	3166 W TERANIMAR DRIVE		TELEPHONE:	(714) 723-0129
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92804
CAPACITY:	6	CENSUS:	DATE:	09/21/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:03 AM
MET WITH:	Stephanie Johnson, Administrator		TIME COMPLETED:	11:50 AM

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On today’s date, Licensing Program Analyst (LPA) LPA Rosie Quiroz conducted an unannounced visit for the purpose of conducting a required annual inspection. LPA Quiroz was greeted and granted entry into the facility by Administrator Stephanie Johnson, and explained the nature of the visit. This facility is licensed to provide services to age range 60 and over, 6 Ambulatory Residents, of which 6 may be bedridden, Room#4 for Ambulatory only, and has a hospice waiver for four (4) residents. Administrator (AD) AD Stephanie Johnson has an Administrator Certificate with expiration date of 08/26/2022.

During today's visit. LPA Quiroz provided consultation on California Code of Regulation Title 22, and COVID-19 guidance in RCFE facilities.

On or about 09:45am LPA Quiroz along with AD Johnson toured the inside and outside of facility. Staff working at facility were observed to be wearing face masks upon arrival to facility. There are five residents in care and there are no active COVID-19 cases. During today's inspection visit, LPA Quiroz interacted with residents in care. Five of five residents appeared to be clean and well taken care of. LPA Quiroz observed required department postings in the facility as well as hand washing signs in the restrooms. All restrooms observed to have ample soap/sanitizer and appeared clean. LPA Quiroz inspected residents’ bedrooms and appeared clean and sanitary. All bedrooms observed to have all required components. LPA Quiroz observed two check in stations, one located in front entrance and one in the back of the facility. Facility is taking temperatures daily and documenting results. LPA Quiroz observed the emergency disaster and evacuation plan. Facility has back-up emergency food and water supply as well as ample PPE supplies. LPA Quiroz toured the outside of the facility and observed seating area with table and chairs for resident’s enjoyment. Facility has completed the LIC808 Mitigation plan dated 7/14/2021, and approved the plan on today’s visit.

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SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2021

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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: TERANIMAR HOMECARE	FACILITY NUMBER: 306005606
	VISIT DATE: 09/21/2021

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During today's inspection visit, LPA Quiroz reviewed five of five resident records.

Based on the observation made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with Administrator Johnson, and a copy of this report was provided to Administrator Johnson at exit.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021

LIC809 (FAS) - (06/04)

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