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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803047
Report Date: 01/30/2024
Date Signed: 01/30/2024 11:13:29 AM


Document Has Been Signed on 01/30/2024 11:13 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:TERENE MANORFACILITY NUMBER:
496803047
ADMINISTRATOR:SHEVICK, TERESITAFACILITY TYPE:
740
ADDRESS:120 SAVANNAH WAYTELEPHONE:
(707) 837-9915
CITY:WINDSORSTATE: CAZIP CODE:
95492
CAPACITY:6CENSUS: 4DATE:
01/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:41 AM
MET WITH:Teresita Shevick (Administrator)TIME COMPLETED:
11:28 AM
NARRATIVE
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required Inspection and was greeted by Administrator, Teresita Shevick. Required postings observed. Annual fees current.

LPA/Administrator initiated a tour of the facility at 9:00 AM and made the following observations: Facility consists of two stories but residents occupy only the lower floor. Door to staff living areas were locked. Laundry room was also locked. Facility was a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Water temperature in resident's bathroom measured at 112.5, 112.8 and 110.5 degrees F which are within allowable range of 105 to 120 degrees F. Extra hygiene products and linens were available. Bathrooms had required bath mats and grab bars. Toxins was inaccessible to residents in care. Facility has at least two days of perishable and one week of non-perishable foods. Medications were centrally stored and locked in a cabinet and in a locked box in the refrigerator. Facility has a camera without audio in the common living room. LPA confirmed that there were not any cameras in resident rooms. Fire extinguisher was last inspected January, 2023. Smoke alarms tested were operational as well as the Carbon Monoxide detector. Exit doors have auditory alerts that were functional at time of visit. Last disaster drill conducted on 2018. Medications & medication records reviewed.

File review was initiated at 9:30 AM. Three staff files and four resident files were reviewed. All residents care plan and medical assessment has been updated within the last 12 months. Staff have required 1st aid/CPR certificates, but 3 out of 3 (S1, S2 & S3) staff have not completed their 20 hours required annual training. Administrator Certificate for Administrator, Teresita Shevick 6006577740 expires 8/13/25.

Administrator to submit updates of the following documents by 2/6/24: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500) and a copy of Liability Insurance.
Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and copy of this report was given.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2024
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 01/30/2024 11:13 AM - 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: TERENE MANOR
FACILITY NUMBER: 496803047

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's/Administrator observation, interview and record review, the licensee did not comply with the section cited above in 3 out of 3 staff have not completed their 20 annual training hours requirement, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/13/2024
Plan of Correction
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Administrator to ensure staff complete their training hours requirement by poc due date. Administrator will submit LIC9098 form to CCL certifying that staff have completed the annual required training hours.
Type B
Section Cited
HSC
1569.695(c)
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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Based on LPA's/Administrator observation, interview and record review, the licensee did not comply with the section cited above by not conducting a disaster drill within the last quarter, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/13/2024
Plan of Correction
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Administrator will conduct a disaster drill with staff and will submit a LIC9098 self-certification form to CCL notifying the department that disaster drill have been conducted by poc due date to clear citation.
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 MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2024
LIC809 (FAS) - (06/04)
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