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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700494
Report Date: 11/30/2023
Date Signed: 11/30/2023 05:36:13 PM

Document Has Been Signed on 11/30/2023 05:36 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
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: 3DATE:
11/30/2023
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Anastasia BurtonTIME COMPLETED:
04:00 PM
NARRATIVE
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A Microsoft Teams meeting was held today 11/30/2023 at 3:30pm to discuss the exception request to use a seat belt guard for resident #1. The attendees of the meeting were: Representatives of Community Care Licensing (CCL) Licensing Program Manager (LPM) Stephen Richardson, Licensing Program Analyst (LPA) Victoria Brown and Representative of Telecare Corporation, Administrator Anastasia Burton.

LPA began the meeting by stating the purpose of the meeting and introductions began. The administrator proceeded to review the purpose of the request and the care needs and history of the resident along with noted behaviors. The facility had been in communication with other agencies such as Client Rights, San Diego Regional Center, and College Hospital regarding the relocation of resident to Telecare Herald House. During the communications there were meetings and reviews of resident records, assessments, and history of behaviors. The team has set in place plans to assist the resident by stabilizing behaviors, teaching safety for self and others with a goal of being more independent.

During the review of documentation submitted to Community Care Licensing (CCL) and confirmation during today’s visit, it was revealed that the facility transported the resident using the seat belt guard prior to having an approved exception in place. Administrator reported that there were no incidents to report during the transporting of the resident using the device.

Based on the documentation reviewed and admittance the guard was used prior to the exception being granted, the facility shall be cited a deficiency during this visit.

See 809C for Continuation...
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE: DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: TELECARE HERALD HOUSE
FACILITY NUMBER: 342700494
VISIT DATE: 11/30/2023
NARRATIVE
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809 continued...

Community Care Licensing expectations:
-Facility to provide a schedule/timeline of the community activities at which time the resident will be training to become more independent and to reduce behaviors.
-Facility to provide ongoing updates, incidents and/or re-assessments
-Facility shall always abide by the language in the approved exception

Per CCR Title 22, Div 6, Ch1, the following deficiencies are cited on the attached 809D during this visit.

If any of the cited deficiencies are not corrected by the noted due dates, civil penalties may be assessed.

The Administrator was provided with a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights.

An exit interview was held. Administrator agreed to a copy of this report being provided via email and an electronic email read receipt confirms receiving these documents.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/30/2023 05:36 PM - It Cannot Be Edited


Created By: Victoria Brown On 11/30/2023 at 05:20 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: TELECARE HERALD HOUSE
FACILITY NUMBER: 342700494

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/30/2023
Section Cited
CCR
80024(b)(4)

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Waivers and Exceptions
The licensing agency shall have the authority to approve the use of alternate…equipment, … under the following circumstances: The licensing agency shall provide written approval or denial of the request.
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The Licensee/Administrator shall submit an exception request along with pertinent documentation to be reviewed by the Department.

POC cleared prior to today’s visit.
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This requirement is not met as evidenced by:Based on documentation submitted and Administrator confirming the seat belt guard was used on R1 during transportation prior to having an approved exception. This poses an immediate health and safety risk to residents in care.
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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:Victoria Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2023


LIC809 (FAS) - (06/04)
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