425802136-6-12-2026-29-AS-MRAN-DUZ2EB-20260612171939

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425802136
Report Date: 06/12/2026
Date Signed: 06/12/2026 05:20:00 PM

Document Has Been Signed on 06/12/2026 05:20 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	TELECARE CARMEN LANE		FACILITY NUMBER:	425802136
ADMINISTRATOR/ DIRECTOR:	HANNA DIAZ		FACILITY TYPE:	772
ADDRESS:	212 WEST CARMEN LANE STE 201		TELEPHONE:	(805) 212-7680
CITY:	SANTA MARIA	STATE: CA	ZIP CODE:	93458
CAPACITY: 12		CENSUS: 11	DATE:	06/12/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:14 AM
MET WITH:	Alexandria Neal		TIME VISIT/ INSPECTION COMPLETED:	05:30 PM

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Licensing Program Analyst (LPA) Rankin arrived unannounced to conduct the required annual visit at 9:14 a.m. LPA met with Alexandria Neal, Clinical Director and Designee at approximately 9:35 a.m. and informed them of the reason for the visit. LPA toured the physical plant areas to ensure there are no health and safety hazards and that facility is following Title 22 Regulations.

KITCHEN: Knives are stored in a locked drawer in the kitchen. Kitchen appliances were in operable condition and noted to be clean. The facility has a sufficient supply of perishable and non-perishable food. Meals are pre-scheduled and menu for the day was noted. Items for the menu were observed in the refrigerator. An updated Client allergy list was printed during LPA visit, this document provides cooking staff of any food allergies.

Common areas: Common areas include a dining room, living room, and a computer area. Furniture observed to be in good condition. Smoke detectors and carbon monoxide detectors were tested, updated detectors are needed. The fire extinguisher was charged and serviced in 1/14/26. Dining room has a microwave, a toaster, and a coffee dispenser, for client use, outside of the locked kitchen. Clients are assigned chores and maintain client areas, staff oversee that areas are cleaned.

The facility has outdoor seating for client use with plenty of shade. No bodies of water are noted. Laundry room is locked and used for storage of washer and dryer, detergents and other miscellaneous items including hygiene products and additional clothing. Multiple thermostats were noted. Temperature was 68 – 69 degrees throughout the facility.

Restrooms: The three client restrooms were reviewed, restrooms were clean and in operating condition, a work order was placed during LPA visit for a replacement shower head due to green residue build up. The bathrooms were sufficiently stocked with soap and paper towels, and secured grab bars were present. Continued on 809-C

NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Melisa Rankin
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/12/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2026

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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Document Has Been Signed on 06/12/2026 05:20 PM - It Cannot Be Edited

Created By: Melisa Rankin On 06/12/2026 at 04:54 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: 06/12/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

81075(f)

(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above when 5 out of 5 staff files reviewed, do not have evidence of current first aid training maintained in their files which poses/posed a potential health, safety risk to persons in care.
	POC Due Date: 07/10/2026
	Plan of Correction
1 2 3 4	Facility has a scheduled CPR and First Aid training on 7/10/26. Administrator will provide documentation of all staff obtaining updated First Aid Certification.

Section Cited


	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above when review of medication showed, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Kelly Burley
NAME OF LICENSING PROGRAM MANAGER:

	Melisa Rankin
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/12/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2026

LIC809 (FAS) - (06/04)

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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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: TELECARE CARMEN LANE	FACILITY NUMBER: 425802136
	VISIT DATE: 06/12/2026

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Bedrooms: There are six (six) resident rooms consisting of two (2) single rooms and four (4) shared rooms. LPA observed all rooms to have beds, nightstands, and dressers, they appeared to be clean and without odor, except for one room. Client in the room is in a single occupancy room and is being encouraged and prompted by staff to maintain their area, ultimately Facility House rules may be reinforced to motivate participation and compliance.

Records: LPA reviewed resident and staff records. LPA reviewed five (5) resident files for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, and current needs and services plans. All files are complete.

The LPA reviewed five (5) staff files for, but not limited to, the following: personnel records, health screening, TB testing, current first aid certification, and annual training. All files complete with the exception of 5 out of 5 randomly reviewed staff do not have valid first aid certification, citation given.

EMERGENCY AND DIASTER PLAN: Facilities Emergency and Disaster Plan was reviewed. The unique clientele and support needed during an event was discussed. Drills are done monthly on all shifts. Two stair chairs are available, one at each stairwell.

Annual visit not completed, LPA will return at a later date.

Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC809-D).

Exit interview conducted, appeal rights printed, and a copy of this report issued.

NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Melisa Rankin
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/12/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2026

LIC809 (FAS) - (06/04)

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