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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604233
Report Date: 04/06/2022
Date Signed: 04/06/2022 04:22:57 PM

Document Has Been Signed on 04/06/2022 04:22 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:OUIDIANI, CHEDLIAFACILITY TYPE:
735
ADDRESS:1650 TARLETON STTELEPHONE:
(619) 323-0804
CITY:SPRING VALLEYSTATE: CAZIP CODE:
91977
CAPACITY: 6CENSUS: 5DATE:
04/06/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Cesiah Serrano, House ManagerTIME COMPLETED:
12:35 PM
NARRATIVE
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Licensing Program Analyst (LPA), Tiffany Holmes conducted an unannounced case management visit. LPA Holmes introduced herself and was allowed entry into the facility and explained the purpose of the visit to Cesiah Serrano, House Manager.

Today’s visit was regarding client health checks. During today’s visit LPA toured the facility inside and out and observed other pertinent items in the facility.

*LPA observed the Medication Administration Record (MAR) and medications for one client. House manager admits that they did not give Client 1 (C1) their nasal spray for 3 days. Dates of incidents: 03/28/2022, 03/30/2022 & 03/31/2022. LPA also observed two couches in the back yard with the springs exposed.

*LPA observed dog feces in the backyard along with cushion stuffing (from the couch pillows) all around the back yard. LPA also observed six holes in the wall/door that need to be fixed and two outlets in the master bedroom that need to be fixed.

*LPA observed a rusted rake that was broken outside in the backyard behind the shed.

Based on todays visit, these deficiencies are cited in accordance to the California Code of Regulations, Title 22, Division 6, Chapter 1, and is noted on the attached LIC809-D.

An exit interview was conducted with Cesiah Serrano, House Manager A copy of this report, and the Licensee/Appeal Rights (9058 01/16) were provided via e-mail. An electronic read receipt verifies receipt of these documents.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/06/2022
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 3
Document Has Been Signed on 04/06/2022 04:22 PM - It Cannot Be Edited


Created By: Tiffany Holmes On 04/06/2022 at 11:14 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: TARLETON HOUSE
FACILITY NUMBER: 374604233

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/07/2022
Section Cited
CCR
80087(g)

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Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.This requirement was not met as evidenced by: There was a broken rake that was outside in the backyard behind the shed and two couches with springs exposed.
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House manager immediately removed the rake& broken piece from behind the shed as well as removed the two couches from the back yard while LPA was watching.
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This poses an immediate health and safety risk to the clients in care.
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House manager will educate all staff members about the requirements. House manager will also have a staff training on safety precautions in the facility and submit a copy & sign sheet to CCL by 04/07/2022
Type B
04/15/2022
Section Cited
CCR80075(b)(B)(C)

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Clients shall be assisted as needed with self-administration of prescription &nonprescription medications.Once ordered by the physician the medication is given according to physician's directions.A record of each dose is maintained in the client's record. The record shall include the date and time the PRN medication was taken, the dosage taken,and the client's response.This requirement was not met as evidenced by: review of C1 MARs and C1s
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House manager observed the error and started giving the medication correctly to C1. House mgr & staff will attend medication training from an outside agency.
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medications that was not given tfor 3 days on 3/28,03/30,03/31 2022. This poses a potential health and safety risk to the clients in care.
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 Once completed, they will submit copies of the training certificate and sign in sheet to CCLD by POC due date, 04/15/2022.
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:Simon Jacob
LICENSING EVALUATOR NAME:Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:
DATE: 04/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 04/06/2022 04:22 PM - It Cannot Be Edited


Created By: Tiffany Holmes On 04/06/2022 at 11:14 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: TARLETON HOUSE
FACILITY NUMBER: 374604233

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/22/2022
Section Cited
CCR
80087(a)

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The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.This requirement was not met as evidenced by observation
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House manager cleaned up dog feces and all the cushion filling that was scattered around backyard while LPA was at the facility. House mgr will fix walls/door and two outlets by 04/22/2022. Mgr will send in photos walls/door and outlets by POC date of 04/22/2022
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of dog feces, pillow cushion stuffing spread through the bakyard and 6 holes in the walls/door and two outlets that were broken. This poses a potential safety risk to clients 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:Simon Jacob
LICENSING EVALUATOR NAME:Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:
DATE: 04/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2022


LIC809 (FAS) - (06/04)
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