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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700494
Report Date: 07/11/2024
Date Signed: 07/11/2024 12:12:37 PM

Document Has Been Signed on 07/11/2024 12:12 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/
DIRECTOR:		BURTON, ANASTASIAFACILITY TYPE:
738
ADDRESS:12956 ALTA MESA RDTELEPHONE:
(209) 748-2513
CITY:HERALDSTATE: CAZIP CODE:
95638
CAPACITY: 4CENSUS: 3DATE:
07/11/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Anastasia BurtonTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 7/11/24 at 9:10a to obtain additional information regarding an Incident report received on 6/14/24. LPA met with Gabrielle Berard, Office Coordinator and stated the purpose of the visit.

The incident report indicated that on 5/25/24 there was 3 missed medications by Resident #1(R1) due to R2 having a behavior. Community Care Licensing (CCL) also received notification that the Licensee did not notify Regional Center (RC) of the incident until 5/30/24. LPA observed that CCL received the incident report on 6/14/24, 20 days after the incident and RC received their report 5 days after the incident.

CCL also received an incident report for a medication error on 6/23/24 for R2. During this error, S3 noted medication was passed on the MAR but the medication was still present in the bubble pack. An interview with S3 concurred that the medication was missed during the shift.

During todays visit, LPA interviewed Staff #1 (S1-S3). Based on the interviews, S1-S3 concur that R1 and R2 missed medications with no adverse reactions and physicians were notified.

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. Copy of this report provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE: DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/11/2024
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
Document Has Been Signed on 07/11/2024 12:12 PM - It Cannot Be Edited


Created By: Victoria Brown On 07/11/2024 at 11:29 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: TELECARE HERALD HOUSE
FACILITY NUMBER: 342700494

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/12/2024
Section Cited
CCR
80061(b)

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Reporting Requirements
Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event.
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Licensee shall submit by fax a letter stating all reporting requirements shall be upheld at all times by Designee/Administrator.

POC cleared during visit
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This requirement is not met as evidenced by:Based on observation of dated documentation the licensee did not submit SIRs timely to CCL nor RC.
This poses an immediate health and safety risk to residents in care.
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Type A
07/12/2024
Section Cited
CCR85365(h)(10)

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Personnel Requirements
In addition to any other required training, ...shall also address the following: Assistance to clients with prescribed medications, including required documentation.
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Licensee conducted medication re-training (In-service) for all staff on 6/26/24.

POC cleared prior to todays visit.
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This requirement is not met as evidenced by:Based on admittance by staff that medications were missed on 2 different dates.
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: 07/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2024


LIC809 (FAS) - (06/04)
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