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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803722
Report Date: 03/09/2023
Date Signed: 03/09/2023 02:58:59 PM

Document Has Been Signed on 03/09/2023 02:58 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:TAMARA HOMEFACILITY NUMBER:
496803722
ADMINISTRATOR:DIMACULANGAN, JOANA GILDAFACILITY TYPE:
734
ADDRESS:105 TAMARA WAYTELEPHONE:
(707) 836-4485
CITY:WINDSORSTATE: CAZIP CODE:
95492
CAPACITY: 4CENSUS: 3DATE:
03/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Administrator, Joana DimaculanganTIME COMPLETED:
03:10 PM
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Licensing Program Analyst (LPA) Victoria Bertozzi arrived unannounced to conduct an Annual Required inspection and met with Administrator, Joana Dimaculangan.

Upon arrival, LPA observed that staff continue to wear masks per current guidance. LPA discussed the recent PIN that allows facilities to discontinue Covid-19 screening but facility has opted to continue to screen visitors, clients and staff. LPA initiated a tour of the facility around 12:00pm and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Client rooms were furnished per regulation. Water temperature in client bathroom measured at109 degrees F which is within the range of 105 to 120 degrees F allowed per regulation. Extra hygiene products and linens were available. Kitchen cabinet containing cleaning supplies was locked. Additional cleaning supplies and disinfectants are stored in locked cabinets located outside. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation. Medications were centrally stored and locked. Facility has a back-up generator in case of power failure that is maintained by a vendor. Emergency food and water supplies were stored in a closet near the front door.

Fire extinguisher was last inspected August 2022. Facility has hardwired combination Smoke/Carbon Monoxide detectors located throughout the facility that were tested and operational. Fire doors were functional during test. Most recent fire/disaster drill was conducted February 9, 2023.

Five staff files and three client files were reviewed. Staff have required First Aid and CPR certificates. Administrator Certificate for Administrator Joana Gilda Dimaculangan 6053604735 expires 9/11/2023. Medications and medication records were reviewed. Client P&I was also reviewed. LPA conducted staff interviews but was unable to interviews clients.

Continued on LIC809C
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE: DATE: 03/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/09/2023
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: TAMARA HOME
FACILITY NUMBER: 496803722
VISIT DATE: 03/09/2023
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Continued from LIC809

Administrator and LPA discussed their Emergency Disaster Plan and Infection Control Plan.

Licensee/Administrator to submit updates of the following documents by 4/09/2023:


LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan (If changes)
Infection Control Plan (If changes)
LIC 9020 Register of Facility Client’s/Resident’s

No deficiencies cited during this inspection
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2023
LIC809 (FAS) - (06/04)
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