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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700494
Report Date: 03/16/2022
Date Signed: 03/16/2022 03:44:28 PM

Document Has Been Signed on 03/16/2022 03:44 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:TELECARE HERALD HOUSEFACILITY NUMBER:
342700494
ADMINISTRATOR:BURTON, ANASTASIAFACILITY TYPE:
738
ADDRESS:12956 ALTA MESA RDTELEPHONE:
(209) 748-2513
CITY:HERALDSTATE: CAZIP CODE:
95638
CAPACITY: 4CENSUS: 4DATE:
03/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Anastasia BurtonTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christina Valerio and LPA Jamie Ivey Canady arrived at the facility unannouced to conduct a required annual inspection. LPAs had their temperature taken upon entry. Staff confirmed no staff or residents have displayed any signs or symptoms of COVID-19 in the last 10 days.

LPAs completed the infection domain tool during the visit. The facility has one entry point where staff are screened prior to starting their shift. Facility staff are said to clean multiple times per shift. COVID-19 signs regarding social distancing, hand washing, infection control, and prevention strategies were observed throughout the facility. Staff were observed wearing masks during the visit.

LPAs toured the physical plant interior and exterior to ensure compliance with Title 22 regulations. All emergency exits were clear from obstructions. A two-day supply of perishable foods and a seven-day supply of non-perishable foods were observed in the refrigerators and freezers. An emergency supply of food and water was observed. Medication cabinet, cleaning supplies, and sharps were locked away and inaccessible to residents in care. Hot water was measured at 148*F, which is out of the regulatory range of 105*F - 120*F. Room temperature was set to 74*F. LPAs observed floors with cracks in between the entryway walkway. A TA was provided during the visit. All required furniture and furnishings were observed in the resident bedrooms and bathrooms. Fire extinguishers were observed to be charged and within compliance with last check on 08/16/2021.

Per California Code of Regulations, Title 22, Division 6, deficiencies were observed during this visit and can be found on LIC 809-D. An exit interview was held, and a copy of the report was left at the facility with the Administrator Anastasia Burton.



SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/16/2022
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 03/16/2022 03:44 PM - It Cannot Be Edited


Created By: Christina Valerio On 03/16/2022 at 01:39 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: TELECARE HERALD HOUSE

FACILITY NUMBER: 342700494

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 03/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(2)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (2) Taps delivering water at 125 degrees F (51.6 degrees C) or above shall be prominently identified by warning signs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 2 out of 3 bathrooms, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/17/2022
Plan of Correction
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Licensee called property management while LPAs were present. Licensee stated property management will be coming out to fix the water heater. Licensee to have water temperature within regulatory range of 105*F - 120*F by POC due date 03/17/2022.
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:Stephen Richardson
LICENSING EVALUATOR NAME:Christina Valerio
LICENSING EVALUATOR SIGNATURE:
DATE: 03/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/16/2022


LIC809 (FAS) - (06/04)
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