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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803047
Report Date: 01/21/2025
Date Signed: 01/21/2025 03:59:05 PM

Document Has Been Signed on 01/21/2025 03:59 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:TERENE MANORFACILITY NUMBER:
496803047
ADMINISTRATOR/
DIRECTOR:		SHEVICK, TERESITAFACILITY TYPE:
740
ADDRESS:120 SAVANNAH WAYTELEPHONE:
(707) 837-9915
CITY:WINDSORSTATE: CAZIP CODE:
95492
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
01/21/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Teresita Shevick-AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alviso arrived unannounced to conduct a required- 1 year inspection, on 1/21/25 at approximately 12:30pm, and met with Administrator Teresita Shevick. LPA observed a caregiver on duty during the inspection, Cindy Magnuson.

Facility is fire cleared for six (6) non-ambulatory residents, of which one (1) may be bedridden. Facility has an approved dementia plan of operation. Hospice waiver approval is for three (3) residents. Facility has a required infection control plan. Facility has a required emergency disaster plan. Per file review. last emergency drills were held on 12/12/24, Earthquake drill, and on

LPA reviewed five (5) resident files; All records were complete.

LPA reviewed four (4) staff files, including training. All staff had required criminal record clearance. All staff had required first aid certification. S4, caregiver had both first aid and CPR certification.

LPA toured the facility with the Administrator. Hot water was checked at 117.1 degrees Fahrenheit, which is within regulation. The facility was observed to be at a comfortable temperature. The food supply was sufficient in perishable and non-perishable items. All exits had working auditory alarms, all exits were clear and unobstructed. There was a sufficient supply of paper products, cleaners/disinfectants, personal protective equipment (PPE), and hygiene products. There was sufficient lighting in all common areas, resident rooms, hallways, and bathrooms. Sufficient furnishings throughout the facility for resident use. Fire extinguisher was serviced and tagged as required.

LPA discussed fire clearance and regulation requirements with the Administrator regarding the backyard walkways and fire exit path are to remain clear and unobstructed at all times; Administrator stated to the LPA their understanding of the above information discussed.

Continued on LIC809C...
Bethany MoellersTELEPHONE: (707) 588-5040
Dina AlvisoTELEPHONE: (707) 588-5082
DATE: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/21/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: TERENE MANOR
FACILITY NUMBER: 496803047
VISIT DATE: 01/21/2025
NARRATIVE
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LPA is requesting the following documents be updated and submitted by 2/21/25:
LIC308 - Designation of Administrator Responsibility
LIC500 - Personnel Report
LIC610E-Emergency Disaster Plan (ensure to review and update as needed/required)
Infection Control Plan (ensure to review and update as needed/required)
LIC400 Handling of Client Cash Resources (include copy of surety bond if handling cash)
Copy of Current Liability Insurance
Resident Roster
Copy of current Administrator Certificate.

The following deficiencies were observed by the LPA during the inspection:

Per LPA's file review, there have been two (2) emergency disaster drills held, 12/24 & 10/24, both were earthquake drills; In review of facility emergency disaster drills the requirement has not been met. This deficiency will be cited, HSC 1569.695 (c) -A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill, see LIC809D.

Per LPA file reviews, staff, S1, S2, & S3, all lack current CPR certification.This deficiency will be cited, HSC 1569.618(c)(3)-Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR, see LIC809D.

Deficiencies 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 with Administrator/Licensee Teresita Shevick.
Appeal Rights provided to the Administrator.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/21/2025 03:59 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: TERENE MANOR
FACILITY NUMBER: 496803047

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/21/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Per LPA file reviews, staff, S1, S2, & S3, all lack current CPR certification, the licensee did not comply with the section cited above in [3] out of [4t] staff, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/24/2025
Plan of Correction
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Licensee to ensure that all staff have current first aid and CPR certification as required for direct care staff. Submit proof of S1, S2, and S3 having obtained CPR certification, copy of certification cards. POC due 1/24/25.
Section Cited
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Per LPA's file review, there have been two (2) emergency disaster drills held, 12/24 & 10/24, both were earthquake drills; In review of facility emergency disaster drills the requirement has not been met, the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/27/2025
Plan of Correction
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Licensee to ensure the facility has quarterly emergency disaster drills as required. Licensee to submit facility's plan to ensure required emergency disaster drills are held quarterly, and per the direction of one of the drills to be an evacuation drill, and the other drills to be a different emergency scenario. Plan of correction due no later than 1/27/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bethany MoellersTELEPHONE: (707) 588-5040
Dina AlvisoTELEPHONE: (707) 588-5082

DATE: 01/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/21/2025

LIC809 (FAS) - (06/04)
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