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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496830783
Report Date: 09/30/2021
Date Signed: 09/30/2021 10:41:24 AM

Document Has Been Signed on 09/30/2021 10:41 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:ANAMOR HOMEFACILITY NUMBER:
496830783
ADMINISTRATOR:TATAD, MARIA TERESAFACILITY TYPE:
737
ADDRESS:1204 SHADY OAK PLACETELEPHONE:
(707) 806-2831
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY: 4CENSUS: 3DATE:
09/30/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrators, Maria Tatad and Roselyn JequintoTIME COMPLETED:
10:51 AM
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Licensing Program Analyst (LPA) Victoria Willis arrived unannounced, to conduct an Annual Required inspection and was greeted by facility staff. Administrators, Maria Tatad and Roselyn Jequinto arrived later. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival, LPA observed that the facility has Covid related posters on the exterior door as well as a hand sanitizer receptacle. LPA's temperature was checked upon entry to the facility. Sign-in document for visitors includes standard Covid-19 screening questions. LPA conducted a walk-through of the facility and observed Covid-19 posters throughout that included hand washing signs in restrooms. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer was observed throughout the facility specifically outside of each client room. Clients are encouraged to wear masks when in the community and staff are required to wear them while in the facility. Observed staff had masks on during this visit.

LPA and Administrators discussed client activities and visitation. Facility has a designated visitation area.

Caregivers have completed Personal Protective Equipment (PPE_ training and have been N-95 Fit tested. Commonly touched surfaces are disinfected on each shift.

Facility has submitted their Covid Mitigation Plan and it has been reviewed by CCL. Facility has more than a 30 day supply of PPE including but not limited to masks, face shields, gowns and hand sanitizer. PPE is accessible to staff who need it. Facility maintains a 30 day supply of medication.

LPA confirmed that unvaccinated staff are being tested weekly per current CCL guidance. LPA also discussed the most recent PINs that have been sent out by the Department including but not limited to PIN 21-44-ASC and PIN 21-40-ASC.


Administrators and LPA discussed their Emergency Disaster Plan

No deficiencies cited during this inspection.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Willis
LICENSING EVALUATOR SIGNATURE: DATE: 09/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2021
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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