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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415202881
Report Date: 04/28/2025
Date Signed: 04/28/2025 02:13:13 PM

Document Has Been Signed on 04/28/2025 02:13 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:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:10 PM
MET WITH:Kyle LiddleTIME VISIT/
INSPECTION COMPLETED:
02:25 PM
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On April 28, 2025, at 1:15 PM, Licensing Program Analyst (LPA) Kiran Jain arrived unannounced at the facility to conduct a Case Management – Incident visit regarding an incident that occurred on 04/17/2025 when staff (S2) conducted a medication count and discovered that the medication count for Panoprazole 40 mg for resident R1 was off by one (1). Upon arrival, LPA met with the Interim Program Administrator (ADM), Kyle Liddle. The LPA disclosed the purpose of the visit.

LPA interviewed two (2) staff members: ADM and S1, and a Physician’s Assistant (PAS).

ADM stated that S2 conducted the med count at the beginning of their afternoon shift and communicated to them that R1’s med count for one of the medications was off by one (1). ADM called and contacted the physician’s office (PAS) about R1 missing the morning dosage of the Panoprazole 40 mg. ADM talked to PAS and received a verbal authorization from them to administer the missed medication anytime during the day. The medication was given to R1 soon after. R1 didn’t had any side effects. ADM stated a verbal training was conducted with S1 to review MAR and proper forms for initialing and going med by med verification with the fellow DSP.

ADM dialed and connected the phone with Physician Assistant (PAS) for LPA to have a conversation with the PAS. The PAS stated over the phone that they gave verbal authorization to administer the missed medication to R1 anytime during the day. This medication was for the resident’s acid reflux and would not have any serious side effects.

S1 stated a lot of commotion was going that day at the time when they were preparing on administering the medications for the residents in the office room.

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)
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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)
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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
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Staff wanted access to knives that were locked in the office, staff were clocking in and out at the same time. S1 stated that they verified the medicine but didn’t pop the medicine in the cup for R1. The afternoon shift lead found the error during the med count at the beginning of their shift. S1 stated they have been given verbal training by the ADM to prevent the med errors in the future. S1 stated that clock has been moved to a locked hallway cabinet, and they were not going to open the office door during the medication unless there was an emergency to avoid any distractions.

LPA reviewed R1’s Centrally Stored Medication and Destruction Records, the Medication Administration Record (MAR) to confirm the missed medication dosage was given to R1.

No deficiencies were cited during today's visit.

An exit interview was conducted with the Interim Program Administrator. A copy of this report was provided to the Interim Program Administrator, Kyle 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)
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