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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415202881
Report Date: 04/28/2025
Date Signed: 04/28/2025 01:07:37 PM

Document Has Been Signed on 04/28/2025 01:07 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:TELECARE POPLAR HOUSEFACILITY NUMBER:
415202881
ADMINISTRATOR/
DIRECTOR:		FLORES, AUSTIN KFACILITY TYPE:
737
ADDRESS:2299 POPLAR AVETELEPHONE:
(650) 352-6588
CITY:EAST PALO ALTOSTATE: CAZIP CODE:
94303
CAPACITY: 4CENSUS: 3DATE:
04/28/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Samah Syed and Kylee LiddleTIME VISIT/
INSPECTION COMPLETED:
01:10 PM
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
On April 28, 2025, at 09:00 AM, the Licensing Program Analyst (LPA) Kiran Jain arrived unannounced at the facility to conduct a Required 1-Year Annual inspection. The LPA met with the A.M. Shift Lead (SLD), Samah Syed, and disclosed the purpose of the inspection. The Interim Program Administrator (ADM), Kyle Liddle, joined shortly after. The SLD informed the LPA that the facility had (3) residents in care and (4) staff members present at the time. (1) resident was away at the hospital and (2) residents were at the facility.

At 9:32 AM, the LPA initiated a walk-through of the facility, accompanied by the SLD.

LPA inspected the kitchen and found it clean, with no food preparation and cooking in progress at the time. The appliances were checked and observed to be in working order. The sink was empty, and no dirty dishes were observed. The refrigerator and pantry cabinets were inspected, and sufficient supplies of fresh perishable food for (2) days and nonperishable staples for (7) days were observed. No expired food or stored medications were noted.

LPA inspected the dining area adjacent to the kitchen and found it clean. The dining table and chairs were observed to accommodate the residents, and all the furniture was in good repair. An additional working refrigerator with freezer was observed in the dining area. LPA inspected the living room and observed it clean, with all furniture in good repair. There were sofas, chairs, television, and a coffee table. A non-slip rug was placed under the coffee table and the sofa. Board games, puzzles, and other recreational activity items for residents’ planned activities were also observed. The indoor temperature reading of 71°F on a thermostat was observed in the hallway at the time of the visit. LPA inspected a locked closet in the hallway, containing detergents, soap, and cleaning supplies.

Continued on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Kiran Jain
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2025
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 5
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: TELECARE POPLAR HOUSE
FACILITY NUMBER: 415202881
VISIT DATE: 04/28/2025
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
26
27
28
29
30
31
32
LPA observed a vertically stacked washer and dryer in the hallway. The SLD tested the smoke and carbon monoxide detector located in the hallway in the LPA's presence, and it was found to be functional. Additional smoke and carbon monoxide detectors were observed in all bedrooms and common areas of the facility during the visit. LPA inspected the fire extinguisher mounted on the wall in the office room and found it fully charged, with the last service tag dated 05/15/2024. LPA inspected a locked box containing knives and sharp objects in the main office room.

There were four (4) single occupancy bedrooms and two (2) common bathrooms designated for residents' use. LPA inspected all (4) resident bedrooms and found them clean, well-lit, and equipped with the required furniture. LPA inspected two (2) bathrooms, and found them clean, sanitary, and in good working condition. The bathrooms contained soap, paper towels, a trash can, and non-slip mats/flooring. At 9:46 AM, The hot water temperature at the sink faucet measured at 147.7°F in bathroom #1 and 144.5°F in bathroom #2. SLD stated that all residents like to have hot water showers and is going to put "Hot water in use" warning signs.

LPA toured the backyard area and found all passageways in good condition, clear of obstructions, with no blocking or tripping hazards. No accessible bodies of water were found. A shaded area with outdoor patio furniture in good clean condition were observed. LPA inspected a storage cabinet and observed bedsheets, Christmas decorations, and emergency supply items stored in it.

LPA reviewed five (5) staff personnel records and three (3) resident records. The LPA observed that 3 of 3 residents had an Admission Agreement, Physician's Report, Appraisal Needs and Services Plan, and CSDMR. LPA observed that 5 of 5 staff members had LIC 508 Criminal Record Statements and LIC 503 Health Screening and confirmed that 5 of 5 staff members were associated with the facility.

LPA observed a locked centrally stored medication cart inside the office room. Medications were organized in separate level for each resident. Centrally Stored Medication Records were reviewed and found to be complete. All medication bottles and bubble packs were properly labeled. The medication count was conducted at the start and at the end of each shift.

LPA inspected the first aid kit and found it fully stocked. Emergency Drill Logs were reviewed, and it was observed that Emergency Disaster Drills were conducted monthly, with the most recent drill completed on 03/28/2025.

Continued on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Kiran Jain
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: TELECARE POPLAR HOUSE
FACILITY NUMBER: 415202881
VISIT DATE: 04/28/2025
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
26
27
28
29
30
31
32
The following updated forms are requested to be submitted to CCLD by 05/05/2025:
  • LIC 500: Personnel Report
  • LIC 308: Designation of Facility Responsibility
  • LIC 400: Cash Resources Affidavit
  • Surety Bond
  • Certificate of Liability Insurance
  • Administrator Certificate(s)

No deficiencies were cited during today's visit.

An exit interview was conducted with the Executive Director. A copy of this report was provided to the Interim Program Administrator, Kylee Liddle, whose signature on this form confirms receipt of the report.

NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Kiran Jain
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2025
LIC809 (FAS) - (06/04)
Page: 4 of 5