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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496830783
Report Date: 09/24/2024
Date Signed: 09/24/2024 04:06:34 PM

Document Has Been Signed on 09/24/2024 04:06 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:ANAMOR HOMEFACILITY NUMBER:
496830783
ADMINISTRATOR/
DIRECTOR:		TATAD, MARIA TERESAFACILITY TYPE:
737
ADDRESS:1204 SHADY OAK PLACETELEPHONE:
(707) 806-2831
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY: 4CENSUS: 4DATE:
09/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:14 PM
MET WITH:Maria Teresa Tatad, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by caregiver. Administrator Maria Tatad arrived later. Facility contact information was reviewed.

At approximately 1:30pm LPA and caregiver toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered. Kitchen cabinet containing cleaning supplies was locked. LPA observed residents engaged in a variety of activities: jewelry making, beading, and arts and crafts.

All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Water temperature in sink accessible to residents in care measured at 113.8 degrees F which is within the allowable range of 105 to 120 degrees F.

Fire extinguishers were last inspected 10/6/2023. Smoke/Carbon Monoxide detectors located throughout the facility were operational. Facility’s last quarterly disaster drills were conducted 8/23/2024. Facility has a backup generator for use during a power outage.

At approximately 2:00pm LPA conducted review of 5 staff records. Staff members S1 and S2 did not have fingerprint clearance. S1 and S2 were not presently working on the day of LPA annual visit, but are currently active employees. Admin will suspend S1 and S2 from working in the facility until fingerprint clearance determination is indicated as eligible. LPA discussed with Admin the CDSS letters one receives that indicate a background clearance determination of eligible and showed Admin examples of such letter in their current employees' files (deficiency cited, see 809D **civil penalty assessed**). S2 did not have TB clearance on file and S3's health screen shows positive TB but no clear chest xray (deficiency cited, see 809D).

Continued on 809C...
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE: DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/24/2024
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: ANAMOR HOME
FACILITY NUMBER: 496830783
VISIT DATE: 09/24/2024
NARRATIVE
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Continued from 809...

At approximately 2:30pm LPA conducted a review of 4 resident records. 1/2 rail orders all on file for respective residents.

At approximately 3:30pm LPA and Admin conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet. No deficiencies. Cash resources reviewed. No deficiencies.

Maria Tatad Administrator Certificate 7034221735 expires 1/25/2025. All fees are current as of this time.


Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC500- Personnel Report
LIC308- Designation of Responsibility

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Admin. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with Administrator and a copy of this report was given.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 09/24/2024 04:06 PM - It Cannot Be Edited


Created By: Christi Coppo On 09/24/2024 at 03:43 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: ANAMOR HOME
FACILITY NUMBER: 496830783

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80066(b)(3)(B)
Personnel Records
(b) Personnel records shall be maintained for all volunteers and shall contain the following: (3) For volunteers that are required to be fingerprinted pursuant to Section 80019: (B) Documentation of either a criminal record clearance or exemption as required by Section 80019(e).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA and Admin interview and record review, the licensee did not comply with the section cited above in that S1 and S2 did not have fingerprint clearance, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/25/2024
Plan of Correction
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Facility to submit LIC9098 self-certifying that S1 and S2 will not be present in the facility in any capacity until fingerprint clearance determination is eligible.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Victoria Bertozzi
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 09/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 09/24/2024 04:06 PM - It Cannot Be Edited


Created By: Christi Coppo On 09/24/2024 at 03:43 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: ANAMOR HOME
FACILITY NUMBER: 496830783

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA and Admin observation and record review, the licensee did not comply with the section cited above in that S2 did not have a TB determination on Health Screen or clear chest xray and S3 did not have a clear chest xray, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/15/2024
Plan of Correction
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Facility to submit proof to CCL of clear chest xray for S3 and TB clearance for S2 by plan of correction due date. Photographic proof will be accepted.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Victoria Bertozzi
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 09/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2024


LIC809 (FAS) - (06/04)
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