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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700494
Report Date: 11/04/2022
Date Signed: 11/04/2022 11:12:45 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/24/2022 and conducted by Evaluator Christina Valerio
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220824083100
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:
11/04/2022
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Ona BerardTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Facility staff not meeting the residents needs and service
Facility staff was verbally abusive
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christina Valerio arrived to the facility unannounced to deliver complaint investigation findings. LPA met with facility staff, and explained the purpose of the visit. The department has determined the following as it relates to the following allegations: Facility staff not meeting the residents needs and service, Facility staff was verbally abusive

According to records review, an semi-annual conducted by CDDS revealed the facility did not meet resident needs and service plans due to the following: Facility did not ensure a minimum of 6 hours of QBMP consultation was provided monthly to each consumer and documented accordingly, did not ensure a minimum of 6 hours a month of individualized consultation was provided to each consumer, did not ensure to provide coverage for all shifts and individual needs, and did not ensure all components of a Functional Behavior assessment including trauma-informed care was completed within 7 days of admission. According to records review, the facility is to follow CDDS recommendations to ensure these requirements are met by their next annual.
Continues on LIC 9099 - C…
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 27-AS-20220824083100
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 HOUSE
FACILITY NUMBER: 342700494
VISIT DATE: 11/04/2022
NARRATIVE
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Continued from LIC 9099

According to interviews with staff, two out of four staff members reported that an incident occurred with a staff and a resident. According to a staff, a staff was observed cussing and yelling at a resident after the resident and staff entered the incentive closet. Staff observed the resident's demeanor to become sad and low mood. According to a staff, the incident that occurred was a misunderstanding. The staff member that was with the resident was agreeing with the resident. The resident had entered the incentive closet, which is a shopping area for residents. The resident stated there was nothing the resident wanted. The staff member replied by stating, "yeah, you are right. There is a bunch of crap in there." According to staff, this was the rapport established with the resident and staff.

According to records review, an internal investigation was conducted by Telecare. The investigation found that the staff did use inappropriate language when speaking to the resident. The staff member was held accountable for this action and underwent additional training.

Based on interviews and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited on the attached LIC-9099D. Failure to correct the deficiency may result in civil penalties. Appeal rights were provided. An exit interview was held with facility staff, and a copy of the report was left at the facility.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20220824083100
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 HOUSE
FACILITY NUMBER: 342700494
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/02/2022
Section Cited
CCR
85078(a)(1)
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85078 Responsibility for Providing Care and Supervision (a) In addition to Section 80078, the following shall apply:(1)The licensee shall provide those services identified in the client's needs and services plan as necessary to meet the client's needs. This requirement was not met as evidenced by:
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Licensee stated the administrator will review care plans for each resident and review them with staff to ensure all needs are met. Licensee to hold the review training with all staff. Licensee to send copies of training sign in sheet along with staff schedule for November 2022 to LPA by POC due date.
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Based on records review, the licensee did not ensure 2 out of 4 residents needs and service plans were followed. This poses a potential health and safety risk to residents in care.
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Type B
12/02/2022
Section Cited
CCR
80072(a)(1)
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80072 Personal Rights (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons. This requirement was not met as evidenced by:
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Licensee stated the staff was put on administrative leave and underwent a training related to the incident that occurred. Licensee to send a copy of the completed training by POC due date.
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Based on records review and interviews, staff 1 spoke inappropriately to resident 1, which poses a potential 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.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3