<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700494
Report Date: 09/27/2023
Date Signed: 09/27/2023 10:19:00 AM

Document Has Been Signed on 09/27/2023 10:19 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: 3DATE:
09/27/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:11 AM
MET WITH:Facility StaffTIME COMPLETED:
10:30 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Christina Valerio arrived to the facility unannounced to conduct a case management visit. LPA met with facility staff, and explained the purpose of the visit. LPA learned Anastasia was out of the building conducting off site training for the corporation.

LPA received a summary of Department of Developmental Services’ (DDS) semiannual review that was conducted on site at Telecare Herald House CCH on May 3, 2023 and remotely on May 18, 2023. DDS recommended Telecare Herald House:
    • rectify all outstanding items noted for follow-up within the timelines established by ACRC.
    • follow the program plan, including the administrator making “random night shift visits to provide support and oversight.”
    • provide additional staff training on the criteria for implementation of restraint procedures, which are to be implemented as a last resort.
    • ensure ACRC QBMP documentation is included in each consumer file.
Consistent with recommendations from April 2021, November 2021, May 2022 and November 2022 semi-annual reviews, DDS recommended Telecare Herald House:
    • ensure weekly review of the IBSP is conducted, and includes review of current data, including data on replacement behavior goals.
    • ensure debriefings are documented in accordance with regulatory requirements (22 CCR § 85168.3(a)
    • ensure that full-time administrator hours are completed in accordance with the approved program plan.
Based on the following review, deficiencies are being cited today on the attached LIC 809 - D. Failure to correct deficiencies may result in civil penalties. Appeal Rights provided. An exit interview was held, and a copy of the report was provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 09/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/27/2023
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 09/27/2023 10:19 AM - It Cannot Be Edited


Created By: Christina Valerio On 09/27/2023 at 08:51 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: 09/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/26/2023
Section Cited
CCR
80064(a)(3)

1
2
3
4
5
6
7
80064 Administrator - Qualifications and Duties (a) The administrator shall have the following qualifications: (3) Knowledge of and ability to comply with applicable law and regulation. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee stated administrator will review DDS recommendations and send LPA a statement explaining how each recommendation will be met by POC due date.
8
9
10
11
12
13
14
Based on records review, the licensee did not ensure to comply with applicable laws and regulations during DDS semi-annual review. This poses a potential health and safety risk.
8
9
10
11
12
13
14
Type B
10/26/2023
Section Cited
CCR85168.3(a)

1
2
3
4
5
6
7
85168.3 Manual Restraint or Seclusion Review (a) The Licensee shall ensure that a debriefing occurs in accordance with Section 1180.5(b) of the Health and Safety Code. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee stated Administrator is currently conduct an CPI training for staff. Licensee to send a copy of the in-service training for Telecare Herald House by POC due date.
8
9
10
11
12
13
14
Based on records review, the licensee did not ensure staff provided a debriefing after restraint was used with Resident 1. This poses a potential health and safety risk to residents in care.
8
9
10
11
12
13
14
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: 09/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2