496804146-4-5-2024-21-AS-MCUA-D42PRR-20240405113311

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496804146
Report Date: 04/05/2024
Date Signed: 04/05/2024 11:33:21 AM

Document Has Been Signed on 04/05/2024 11:33 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:	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: 3	DATE:	04/05/2024
TYPE OF VISIT:	Post Licensing	UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Lailani Cenzon (Licensee/acting Administrator)		TIME COMPLETED:	11:48 AM

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) Cuadra arrived announced to conduct a Post-Licensing Inspection and met with Licensee/acting Administrator, Lailani Cenzon. Required postings were observed. The facility received an approved fire clearance dated September 5, 2023 that allows for six non-ambulatory residents. During Pre-licensing LPA discussed with Administrator about the importance to make the second floor area inaccessible for residents in care. Today, LPA/Administrator observed during touring of the facility that the access door located at the interior stairway is still without a lock. Per Administrator, the contractor is in the process of installing a door that it will be able to be locked. LPA will be issuing a technical violation for this issue. In the mean time, staff will ensure the area is inaccessible via observation. All resident rooms are furnished per regulation, the facility was comfortable temperature and passageways were free from obstructions. Bathroom showers have non-skid shower floor and grab bars. Water temperature read at 105.1, 105.4, 106.5, 106.7, 107.2 and 105.1 degrees F which is within regulation of 105 & 120 degrees F. 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 at least two days of perishables and seven days of non-perishables. Smoke and Carbon Monoxide detectors were tested and operational. Facility has a generator in case of a power outage. Activity calendar needs to be updated due to resident's interests. Continued on LIC809C...

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2024

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: TERRA LINDA RESIDENTIAL CARE	FACILITY NUMBER: 496804146
	VISIT DATE: 04/05/2024

NARRATIVE

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Continued from LIC809...

Cameras were observed by LPA/Licensee in the common areas do not have audio. However, the use of cameras in the common area was not included in the admission agreements. The Licensee is required to update the facility's plan of operation when a new service is added and will elaborate an addendum to the resident's admission agreements. Licensee was given instructions of the Guidelines for Video Surveillance to assist in developing a policy. Licensee stated the cameras would be turned off at this time and would be reinstalled until a Video Surveillance policy is created.

At approximate 9:30am LPA initiated file review of three residents and three staff. Admission Agreements were complete. Medical assessments and Care Plans for all residents were current. Two out of three staff do not have training hours complete. Staff have CPR/1st aid updated. Administrator certificate for administrator Lailani Cenzon 6067016740 expires on 5/1/25. Administrator had a discussion with LPA about changing administrators. LPA provided information regarding documents needed to perform the change of Administrator. Medication and medication records were reviewed.

Licensee agreed to submit the following documents by 4/12/24: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500), Emergency Disaster plan (if there are any changes) and 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 was conducted with Licensee and copy of this report was given.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/05/2024 11:33 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: TERRA LINDA RESIDENTIAL CARE	FACILITY NUMBER: 496804146
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/05/2024

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
1 2 3 4	Based on LPA's/Administrator observation, records review and interviews with Licensee, the licensee did not comply with the section cited above in two out of three staff who do not have their annual required training hours complete which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/26/2024
	Plan of Correction
1 2 3 4	Licensee agreed to have staff complete their required training hours and will submit a self-certification form to CCL notifying the Department that staff have completed training hours required by POC due date to clear the ciatation.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2024

LIC809 (FAS) - (06/04)

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