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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700494
Report Date: 12/29/2022
Date Signed: 12/29/2022 09:57:54 AM

Document Has Been Signed on 12/29/2022 09:57 AM - 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:
12/29/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Facility StaffTIME COMPLETED:
09:58 AM
NARRATIVE
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct a case management visit. LPA met with facility staff, and explained the purpose of the visit. Facility staff was informed that if the Administrator has any questions to give LPA a call.

LPA requested the staff schedule for November and December 2022. LPA confirmed that Staff 1 was on the schedule.

According to Guardian Roster, which was obtained on 12/29/2022 at 7:30 AM, Staff 1 was cleared and associated to the facility on 12/13/22. According to an outside agency, the staff has been working at the facility since October 5th, 2022. LPA confirmed that this is correct. Staff currently works NOC shift.

This agency also notified that 4 staff members did not have an updated CPR in the file. Lead staff did not have access to staff files. LPA to return at a later date to review files. LPA requested staff files for all staff to be sent to LPA by 01/06/2022.

Per California Code of Regulations (CCR), Title 22, deficiencies are being cited on LIC 809 - D. Facility staff was made aware that due to the Type A deficiency, a civil penalty in the amount of $500 will be assessed today. An exit interview was held with Facility Lead Staff, and a copy of the report will be provided. Appeal rights provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/29/2022
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 12/29/2022 09:57 AM - It Cannot Be Edited


Created By: Christina Valerio On 12/29/2022 at 08:28 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: TELECARE HERALD HOUSE
FACILITY NUMBER: 342700494

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/30/2022
Section Cited
CCR
80019(e)

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80019 Criminal Record Clearance (e) All individuals... shall prior to working... in a licensed facility:(1) Obtain a California clearance or a criminal record exemption as required by the Department or(2) Request a transfer of a criminal record clearance as specified in Section 80019(f)... This requirement was not met as evidenced by:
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Licensee stated all staff moving forward will be associated to the facility prior to working a shift. Licensee to review 80019, guardian, and finger print transfer procedures. Licensee to send a written statement acknowledging undertsanding of regulation and procedure to LPA by POC due date 12/30/22.
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Based on interviews and records review, the licensee did not ensure Staff 1 was fingerprinted cleared and associated to the facility, which poses an immediate health and safety risk to persons 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:Christina Valerio
LICENSING EVALUATOR SIGNATURE:
DATE: 12/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/29/2022


LIC809 (FAS) - (06/04)
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