496804146-11-13-2023-21-AS-VBEI-CXJUWY-20231113145731

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496804146
Report Date: 11/13/2023
Date Signed: 11/13/2023 02:57:36 PM

Document Has Been Signed on 11/13/2023 02:57 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:	TERRA LINDA RESIDENTIAL CARE		FACILITY NUMBER:	496804146
ADMINISTRATOR:	TRINIDAD, JOEL		FACILITY TYPE:	740
ADDRESS:	625 TERRA LINDA COURT		TELEPHONE:	(707) 542-9653
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95404
CAPACITY:	6	CENSUS: 5	DATE:	11/13/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	12:50 PM
MET WITH:	Applicant, Lailani Cenzon		TIME COMPLETED:	03:07 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Victoria Bertozzi arrived announced to conduct a Pre-Licensing Inspection and met with Applicant, Lailani Cenzon. Applicant has applied for a Change of Ownership of an existing Residential Care for the Elderly Facility. Facility is a two story residence with six single bedrooms, six bathrooms, and common areas. The second story is designated as living space for staff. Residents will not reside or use the second floor. There is a door at the interior stairway that does not lock. To make areas that may pose a risks inaccessible to residents in care, LPA suggested the door be changed to a door that can be locked. In the mean time, staff will ensure the area is inaccessible via observation. All resident rooms are furnished per regulation with a bed, lamp, dresser, chair and bedside table. Bathroom showers have non-skid shower floor and grab bars. Water temperature read at 107 degrees F which is within regulation of 105 & 120 degrees F. Facility has sufficient items used for cooking and eating. Facility has a locked cabinet in the kitchen used for centrally stored medications. Files are stored in a locked office cabinet. Cleaning supplies and toxins are locked in a cabinet in the pantry and an outdoor locked shed. Perishable and non-perishable foods are stored per regulation. Facility has areas inside and outside for visiting and activities. LPA observed a camera in the kitchen and Applicant confirmed that the camera in the kitchen is active and the facility also has exterior cameras. LPA confirmed with Applicant that audio on the cameras were turned off to ensure resident's Personal Rights. Continued on LIC809C

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 11/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2023

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: TERRA LINDA RESIDENTIAL CARE	FACILITY NUMBER: 496804146
	VISIT DATE: 11/13/2023

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Continued from LIC809

Facility received an approved fire clearance dated September 5, 2023 that allows for six non-ambulatory residents. LPA and Applicant discussed the fire clearance request to retain a bedridden resident under the current license. Per Applicant, the individual no longer resides in the facility so a bedridden fire clearance is no longer needed. LPA discussed with Applicant the requirement of having a bedridden fire clearance prior to admitting a resident who is bedridden. Applicant understands. Facility has Smoke and Carbon Monoxide detectors that were tested during the fire inspection. LPA also tested the Carbon Monoxide detector during this inspection. Facility has a generator in case of a power outage.

LPA confirmed with Applicant that they are signed up with the Guardian and Provider Information Notices (PINs). Component III was conducted with Applicant. LPA notified Applicant that once licensed, they will need to complete new Admission Agreements and Care Plans for all residents,

LPA will notify Application Unit so application process may proceed.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 11/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2023

LIC809 (FAS) - (06/04)

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