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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005412
Report Date: 05/31/2023
Date Signed: 05/31/2023 12:01:04 PM

Document Has Been Signed on 05/31/2023 12:01 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:AMHS TELECARE TREEHOUSE CRISIS RESIDENTIAL NORTHFACILITY NUMBER:
306005412
ADMINISTRATOR:JAQUELINE LARAFACILITY TYPE:
772
ADDRESS:2026 W.BEACON AVENUETELEPHONE:
(657) 276-7030
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 6CENSUS: 5DATE:
05/31/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Edward Solis, Jaqueline LaraTIME COMPLETED:
12:15 PM
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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting an Annual Inspection. LPA met with Staff #1 (S1) Edward Solis and discussed the purpose of the inspection. Administrator (AD) Jaqueline Lara arrived during the inspection.

LPA reviewed Infection Control requirements. At about 8:30AM, LPA and S1 conducted a tour of the inside and outside of the facility, common areas, client rooms, kitchen, and garage and observed the following: Structure. This is a one-story home. Facility is a 3-bedroom, 3-bathroom, one-story house with an attached garage that is being used for storage. There is a back yard with a patio cover for the clients. LPA observed there were 2 staff and 4 clients present. Client Bedrooms. The 3 client bedrooms are spacious and will easily accommodate the clients’ furnishings. Furniture for each client bedroom inspected. Staff Bedrooms. There are no staff bedrooms. Bathrooms. Bathrooms were clean, faucets and toilets were operational. Water temperature: tested between 109.5 and 116 F degrees. LPA inspected all rooms in the facility. Linens & Hygiene Supplies. New linens and fully stocked linen closets were observed. Emergency Phone Numbers and Exit Plan: Reviewed. Food Service. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher were observed and tested, including the wired smoke detectors/carbon monoxide detectors. Appliances. Stove burners, microwave, washer, and dryer inspected. Knives: observed locked in the kitchen drawer. Toxins: observed locked in the office and garage. Medication room is locked. First-Aid Kit and Activity Supplies: observed and available. Facility’s licensing fees are paid. At about 9:30AM, LPA reviewed 5 client files and 5 staff files, inspected medications for 5 clients, inspected property and property logs for 5 clients, and interviewed 4 out of 4 clients and 2 out of 2 staff.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE: DATE: 05/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/31/2023
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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Document Has Been Signed on 05/31/2023 12:01 PM - It Cannot Be Edited


Created By: Sean Haddad On 05/31/2023 at 11:38 AM
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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: AMHS TELECARE TREEHOUSE CRISIS RESIDENTIAL NORTH
FACILITY NUMBER: 306005412

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
81075(b)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and records, the licensee did not ensure 2 out of 5 clients recieved assistance with medication as prescribed, as 1 client had an extra pill and 1 client was missing 1 pill based on the medication administrator record, which poses an immediate health and safety risk to persons in care.
POC Due Date: 06/01/2023
Plan of Correction
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Licensee stated they will notify the client's doctor and retrain staff on medication protocols and submit proof to LPA by POC due date.
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:Armando J Lucero
LICENSING EVALUATOR NAME:Sean Haddad
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2023


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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: AMHS TELECARE TREEHOUSE CRISIS RESIDENTIAL NORTH
FACILITY NUMBER: 306005412
VISIT DATE: 05/31/2023
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During the inspection, LPA and AD observed the following: 1 client had 1 extra pill of Metropolol in their bubble pack which the Medication Administration Record indicated had been dispensed and 1 client had 1 pill of Trazodone missing from their bubble pack which the Medication Administration Record indicated had not been dispensed.

Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2023
LIC809 (FAS) - (06/04)
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