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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415202881
Report Date: 01/09/2025
Date Signed: 01/09/2025 02:44:05 PM

Document Has Been Signed on 01/09/2025 02:44 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:
01/09/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:45 AM
MET WITH:Austin FloresTIME VISIT/
INSPECTION COMPLETED:
02:55 PM
NARRATIVE
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On January 09, 2025, at 11:45 AM, Licensing Program Analyst (LPA) Kiran Jain arrived at the facility to conduct a Case Management – Incident visit regarding (3) separate incidents that occurred on 12/13/2024, 12/25/2024, and 12/31/2024. Upon arrival, the LPA was greeted by the Program Administrator (PA) Austin Flores. The LPA disclosed the purpose of the visit.

1) For incident #1, which occurred on 12/13/2024, resident (R1) was given the wrong dosage of medication.

On 01/09/2025, LPA Jain interviewed PA. PA stated that on 12/13/2024, Resident (R1) didn’t receive the correct dosage for their 5 PM evening dose of Lithium Carbonate medicine. R1 was supposed to be given (3) tablets, a total of 900 mg of Lithium Carbonate medication, whereas staff administered only (1) tablet, 300 mg dosage of Lithium Carbonate medication to R1. The next day on 12/14/2024, PA contacted R1’s doctor about the medication error via phone call. The doctor instructed the staff to administer the remaining (2) tablets of Lithium Carbonate medication first thing in the morning and the staff was able to give these (2) tablets of the Lithium Carbonate medication to R1 around 7 AM on 12/14/2024.

On 01/09/2025, LPA Jain reviewed the Medication Administration Record (MAR) for R1. Records indicated that on 12/13/2024, (3) tablets of Lithium Carbonate 300 mg medication were administered to R1.

2) For incident #2, which occurred on 12/25/2024, resident (R2) eloped from the facility to buy an energy drink from the nearby store and about 30 minutes later returned to the facility independently.

PA stated that on 12/25/2024, R2 eloped from the facility around 10:55 AM, while staff S2 was cleaning the bathroom, and S1 was cooking meal in the kitchen. R2 was last observed to be watching TV in the living room. Around 10:45 AM, R2 asked S2 to help with the laundry and came back to living room to watch TV, while S2 went to clean the bathroom. S2 performed (2) perimeter checks of the facility and searched at nearby preferred locations outside the facility but could not find or locate R2. About 30 minutes later, R2 returned to the facility independently. R2 went to a local store to buy an energy drink. R2 cannot leave the facility on his own. R2 has eloped in the past, but this was the first time they had eloped at this facility.

Continued on 809-C.

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Kiran Jain
LICENSING EVALUATOR SIGNATURE: DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2025
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 3
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: 01/09/2025
NARRATIVE
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LPA Jain observed the front door of the facility open without supervision when LPA arrived at facility for the inspection visit. The back door of the facility was observed to be closed. LPA Jain observed auditory alarms working on both front and back doors of the facility.

LPA reviewed R2’s Physician’s Report (LIC 602) dated 08/20/2024, R2 had a primary diagnosis of Moderate Intellectual Dementia, was ambulatory, and was deemed unable to leave the facility unassisted. The facility staff did not ensure that R2 doesn’t leave the facility unassisted.

3) For incident #3, which occurred on 12/31/2024, resident (R1) was given the wrong dosage of medication.

PA stated that on 12/31/2024, Resident (R1) didn’t receive the correct dosage for their 8 PM dose of Allopurinol medicine. R1 was supposed to be given (2) tablets, a total of 200 mg of Allopurinol medication, whereas staff administered only (1) tablet, 100 mg dosage of Allopurinol medication to R1. The next day on 01/01/2025, PA contacted R1’s doctor via phone about the missed medication. The doctor instructed the staff to administer the remaining (1) tablet of Allopurinol medication in the morning to R1 and the staff was able to give (1) tablet of the Allopurinol medication to R1 along with their other morning medications on 01/01/2025.

LPA Jain reviewed the Medication Administration Record (MAR) for R1. Records indicated that on 12/31/2024, (2) tablets of Allopurinol 100 mg medication were administered to R1.

PA stated that staff S4 caught medication error incidents for both12/13/2024 and 12/31/2024 during med count. Med counts were done at the beginning and at the end of each shift.

The deficiencies are being cited based on LPA observations, records reviewed, and interviews conducted in accordance with the California Code of Regulations, Title 22, see LIC809D.

An exit interview was conducted, and Plans of Correction were reviewed and developed with the Program Administrator. A copy of this report and appeal rights were discussed and left with the Program Administrator, Austin Flores, whose signature on this form confirms receipt of these documents.

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Kiran Jain
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 01/09/2025 02:44 PM - It Cannot Be Edited


Created By: Kiran Jain On 01/09/2025 at 02:03 PM
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
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: TELECARE POPLAR HOUSE
FACILITY NUMBER: 415202881

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/10/2025
Section Cited
CCR
80078(a)

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80078 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the client's needs.

This requirement is not met as evidenced by:
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The Program Administrator will develop a plan to ensure residents are being supervised at all times and will conduct regular training with staff to maintain line of sight. Program Administrator will provide a copy of the plan to CCLD by 01/10/25.
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Based on interview conducted and observation, the facility staff did not ensure to prevent resident (R2) from eloping the facility on 12/25/2024. Facility staff did not ensure to keep the front door closed and R2 was deemed unable to leave the facility unassisted, which posed an immediate health, safety or personal rights risk to persons in care.
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Type B
01/16/2025
Section Cited
CCR80075(b)

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80075 Health Related Services (b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement is not met as evidenced by:
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The Program Administrator will develop a plan to ensure correct medications and dosage are always given to the residents and will conduct a training with all the lead staff. Program Administrator will provide a copy of the plan and training to CCLD by 01/16/2025.
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Based on interview conducted and record review the licensee did not ensure the correct prescribed medication dosage was administered to 1 of 3 residents (R1) on 12/13/2024 and 12/31/2024, which poses an potential health, safety or personal rights risk to persons 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:April Cowan
LICENSING EVALUATOR NAME:Kiran Jain
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2025


LIC809 (FAS) - (06/04)
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