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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604233
Report Date: 07/18/2023
Date Signed: 07/18/2023 03:02:28 PM

Document Has Been Signed on 07/18/2023 03:02 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:TARLETON HOUSEFACILITY NUMBER:
374604233
ADMINISTRATOR:CESIAH SERRANOFACILITY TYPE:
735
ADDRESS:1650 TARLETON STTELEPHONE:
(619) 323-0804
CITY:SPRING VALLEYSTATE: CAZIP CODE:
91977
CAPACITY: 6CENSUS: 4DATE:
07/18/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:DSP Angelica Marin and Administrator Cesiah SerranoTIME COMPLETED:
03:10 PM
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management – Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with DSP Angelica Marin. LPA also spoke via phone with Administrator Cesiah Serrano during the visit.

Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office on 07/17/2023. According to the LIC624: from 06/25/2023 through 06/30/2023, Client #1 (C1) did not receive four (4) of their prescribed routine medications. [See LIC 811 Confidential Names List for a description of C1]. The missed doses did not result in any adverse health consequence for C1. On 07/14/2023, Licensee became aware of the above discrepancies.

During today’s visit, LPA performed a brief facility tour and welfare check on C1, verifying that they and their peers were safe. LPA also reviewed pertinent care records and interviewed relevant staff.

Staff interviews revealed additional context which was material to CCLD’s analysis/evaluation of the incident. No deficiencies were observed or cited during today’s visit.

However, LPA provided a Technical Assistance regarding medication assistance under 80075 Health Related Services (refer to the LIC 9102-TA). LPA also provided education to Licensee regarding forms LIC613 (Client’s Personal Rights) and LIC621 (Client/Resident Personal Property and Valuables).

An exit interview was conducted with Serrano and Marin, to whom a copy of this report, the LIC 9102-TA, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2023
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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