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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803722
Report Date: 04/02/2024
Date Signed: 04/02/2024 10:54:19 AM

Document Has Been Signed on 04/02/2024 10:54 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:TAMARA HOMEFACILITY NUMBER:
496803722
ADMINISTRATOR:DIMACULANGAN, JOANA GILDAFACILITY TYPE:
734
ADDRESS:105 TAMARA WAYTELEPHONE:
(707) 836-4485
CITY:WINDSORSTATE: CAZIP CODE:
95492
CAPACITY: 4CENSUS: 4DATE:
04/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:54 AM
MET WITH:Joana Dimaculangan (Administrator)TIME COMPLETED:
11:09 AM
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Licensing Program Analyst (LPA) Cuadra conducted an unannounced Annual Required inspection and case management visit to follow up on another agency report submitted to Community Care Licensing (CCL) and met with Administrator Joana Dimaculangan. All four clients were attending to day program at time of arrival. Contact information reviewed. Annual fees are current.

LPA/Administrator toured the facility which was found to be clean, in good repair and a comfortable temperature. All exits and pathways were free from obstructions. Client bedrooms contained all required furnishings per regulation. Facility maintains the required supply of linens and hygiene products available to care for 4 clients. Hot water temperature in faucets used by clients measured 107.6 degrees F which is within regulation of 105 to 120 degrees F. Toxins are stored in a locked cabinet under the kitchen sink. Medications are centrally stored in a locked cabinet in the hall next to the bedrooms and in a locked refrigerator in the kitchen. Fire extinguishers were charged and tagged as of July, 2023. Smoke detectors and carbon monoxide detectors were tested and operational during inspection. Fire door was working properly. Facility van was inspected while visit was conducted and it has a first aid kit updated and fire extinguisher. Back up generator is on site and tested every Friday and is documented in a log. Last disaster drill conducted on 3/31/24. There is at least a 2 day of perishable and 7 day supply non perishable foods for 2 clients who are on ground diets and thickened liquids. Currently 2 of the 4 clients are fed through G-tubes. LPA was able to verify that facility maintains a 7+ day supply of client prescribed nutritional formulas. LVNs and RNs are responsible for all tube feeds and medications.

Continue on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 04/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/02/2024
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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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: TAMARA HOME
FACILITY NUMBER: 496803722
VISIT DATE: 04/02/2024
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Continued from LIC809...

At approximate 9:30am LPA reviewed 4 staff and 4 client files. 4 of 4 staff were found to have required First Aid & CPR training. All clients have waivers and exceptions on file. Administrator Certificate 7020362735 for Joana Dimaculangan expires 9/11/25. Client cash resources reviewed.

During today's visit, LPA is following up on another agency report submitted to Community Care Licensing (CCL). The agency conducted a visit on 3/14/24 and found some areas of concern that were resolved by 3/29/24 according to another's report received by the Department. However, LPA reviewed medications and their medication records confirming that there are no further issues.

Administrator submitted copies of the following documents during the visit:

LIC 500 Personnel Summary
LIC 308 Designation of Administrative Responsibility
Current Surety Bond
LIC 610 Emergency Disaster Plan

No Deficiencies were cited during todays visit. Exit interview conducted with administrator and a copy of this report was printed for the facility.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 04/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2024
LIC809 (FAS) - (06/04)
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