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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700494
Report Date: 07/19/2022
Date Signed: 07/19/2022 03:50:58 PM

Document Has Been Signed on 07/19/2022 03:50 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: 3DATE:
07/19/2022
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
03:05 PM
MET WITH:Anastasia BurtonTIME COMPLETED:
03:50 PM
NARRATIVE
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On 7-19-22 at 3:05pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit on recent COVID-19 cases within facility. Upon entry into facility, LPA learned from Administrator that 2 staff members tested positive for COVID-19. Staff1 (S1) tested positive on 7-5-22 and S2 tested positive on 7-14-22. LPA interviewed Administrator and reviewed incident report for S1. Based on interview and record review, it was determined that an incident report for S2 was not submitted to licensing department timely.

Based on today's visit, citation is issued under Title 22, Division 6. An exit interview was conducted with Anastasia Burton and a copy of this report was left with Anastasia. Appeal Rights provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 07/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/19/2022
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 07/19/2022 03:50 PM - It Cannot Be Edited


Created By: Michael Bilger On 07/19/2022 at 03:34 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: 07/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/20/2022
Section Cited
CCR
80061(b)(1)(H)

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Reporting Requirements. (b)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...(1)Events reported shall include the following: (H) Epidemic outbreaks.
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Licensee will read regulation 80061 and submit a signed declaration of understanding to LPA by POC due date.

Licensee sent the required incident report to Licensing department during LPAs visit.
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This requirement is not met as evidenced by: Based on interview and record review, S2 received a positive result on 7-14-22, and Licensee did not ensure the reporting of S2's result to Licensing department within the next working day. This 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.
SUPERVISOR'S NAME:Liza King
LICENSING EVALUATOR NAME:Michael Bilger
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2022


LIC809 (FAS) - (06/04)
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