<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496830783
Report Date: 09/22/2022
Date Signed: 09/22/2022 10:40:29 AM

Document Has Been Signed on 09/22/2022 10:40 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
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:
09/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator,,Maria TatadTIME COMPLETED:
10:50 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) Victoria Bertozzi arrived unannounced to conduct an Annual Required inspection and was greeted by staff. Administrator, Maria Tatad arrived later . The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival, LPA observed a large bulletin board near the porch with multiple Covid-19 posters. LPA was greeted by a staff who asked LPA to take a rapid test prior to entry. LPA agreed. Facility has a screening station set up on the porch which includes a thermometer and binders for staff and visitors to sign in and complete a questionnaire with standard Covid-19 screening questions. LPA confirmed with Administrator that facility was conducting vaccination verification per Provider Information Notice (PIN) 21-40-ASC. LPA initiated a walk-through of the facility around 9:25am and observed the following: Facility has COVID-19 posters throughout that include hand washing signs in bathrooms. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is located throughout common areas of the facility. Commonly touched surfaces are disinfected twice per shift. Facility continues to screen clients for Covid-19 daily and maintain documentation.

Facility has a designated visitation area outside and is allowing for visitation inside per CCL guidance. Staff continue to receive training on infection control and Personal Protective Equipment (PPE). LPA and Administrator discussed visitation and activities.

Continued on LIC809C
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE: DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/22/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: ANAMOR HOME
FACILITY NUMBER: 496830783
VISIT DATE: 09/22/2022
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
26
27
28
29
30
31
32
Continued from LIC809

Facility has submitted and CCL has reviewed their Covid Mitigation Plan. Facility has more than a 30 day supply of PPE including but not limited to masks, gloves, and hand sanitizer. Facility maintains a 30 day supply of medication. Fire extinguishers were last serviced November 2021. Facility has a centralized fire system that is maintained by a vendor. The most recent service was August 2022.

Administrator and LPA discussed their Emergency Disaster Plan and Infection Control Plan with the Monkeypox Addendum.



Licensee/Administrator to submit updates of the following documents by 10/22/2022:

LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan (if changes)
LIC 9020 Register of Facility Client’s

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

DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2