425802136-5-17-2023-29-AS-JOLN-CRWTNZ-20230517145334

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425802136
Report Date: 05/17/2023
Date Signed: 05/17/2023 02:53:59 PM

Document Has Been Signed on 05/17/2023 02:53 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 LANE		FACILITY NUMBER:	425802136
ADMINISTRATOR:	CESAR ARGUETA		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: 7	DATE:	05/17/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Alex Briceño, Temporary Administrator and Hana Diaz, Clinical Director		TIME COMPLETED:	03:10 PM

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Licensing Program Analyst (LPA) Jenny Olson arrived at the facility unannounced to conduct a required annual visit at 9:40 a.m. LPA met with Alex Briceño, Temporary Administrator and Hana Diaz, Clinical Director and informed them of the reason for the visit.

LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: Knives are stored in a locked drawer in the kitchen. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food.

Common areas: Living and dining room furniture were observed to be in good condition. Smoke detector and carbon monoxide detector were tested and operational at the time of the visit. The fire extinguisher was charged and serviced 11/29/2022.

The outside area has a covered outdoor area equipped with furniture for client use. No bodies of water noted. The washer and dryer are in a laundry room which is locked and has extra linens..

Restrooms: The three client restrooms were clean and sanitary and in operating condition. The bathrooms were sufficiently stocked with soap and paper towels. Around 2:00 p.m., the hot water temperature measured in the residents restrooms at 121.0 degrees Fahrenheit.

Bedrooms: There are seven (7) resident rooms, which were furnished appropriately.

Records: LPA reviewed resident and staff records at 9:50 a.m. 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 plan. All files were complete except for LIC 613 Resident Rights.

Continued on 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: TELECARE CARMEN LANE	FACILITY NUMBER: 425802136
	VISIT DATE: 05/17/2023

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The LPA reviewed five (5) staff files for, but not limited to, the following: personnel records, health screening, criminal record statements, current first aid certification. All files were complete.

INFECTION CONTROL: Signs were posted that promotes good hand hygiene and symptoms of COVID were present. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate.

LPA interviewed three (3) staff members and one (1) client. All other clients were out in the community.

Exit interview conducted. A copy of the report was provided.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023

LIC809 (FAS) - (06/04)

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