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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425802136
Report Date: 02/07/2024
Date Signed: 02/07/2024 05:43:39 PM

Document Has Been Signed on 02/07/2024 05:43 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:TELECARE CARMEN LANEFACILITY NUMBER:
425802136
ADMINISTRATOR:JESSICA GEIHSFACILITY TYPE:
772
ADDRESS:212 WEST CARMEN LANE STE 201TELEPHONE:
(805) 212-7680
CITY:SANTA MARIASTATE: CAZIP CODE:
93458
CAPACITY: 12CENSUS: 11DATE:
02/07/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Lindsay Cunningham, Interim Regional Director of OperationsTIME COMPLETED:
05:55 PM
NARRATIVE
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Licensing Program Analyst (LPA) Olson conducted a Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint Control #29-AS-20240111153337). The purpose of the visit is to issue a citation for a deficiency observed during the complaint investigation.

During the complaint investigation of complaint #29-AS-20240111153337, the following deficiency was observed: Facility does not have adequate non-perishable food items. Facility immediately sent a staff to go shopping for more food. Interviews with staff revealed food has been in very short recently. Administrator agreed to conduct random fridge and cabinet checks.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (LIC 809-D).

Exit interview conducted, copy of report and appeal rights issued.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE: DATE: 02/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/07/2024
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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Document Has Been Signed on 02/07/2024 05:43 PM - It Cannot Be Edited


Created By: Jeannette Olson On 02/07/2024 at 05:26 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: TELECARE CARMEN LANE
FACILITY NUMBER: 425802136

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/08/2024
Section Cited
CCR
81076(d)(1)

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81076(d)(1) Food Service. Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by:
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Administrator agreed to send LPA pictures of food shopping receipt and a picutre of adquate perishable food by 2/8/24
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Based on observation and interviews, the licensee did not comply with the above cited section when they failed to have adequate food supplies, which posed an immediate health and 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:Kelly Burley
LICENSING EVALUATOR NAME:Jeannette Olson
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2024


LIC809 (FAS) - (06/04)
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