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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425802138
Report Date: 05/30/2023
Date Signed: 05/30/2023 02:43:43 PM

Document Has Been Signed on 05/30/2023 02:43 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 AGNES AVENUEFACILITY NUMBER:
425802138
ADMINISTRATOR:CESAR ARGUETAFACILITY TYPE:
772
ADDRESS:116 AGNES AVENUETELEPHONE:
(805) 457-3724
CITY:SANTA MARIASTATE: CAZIP CODE:
93458
CAPACITY: 10CENSUS: 7DATE:
05/30/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Hanna Diaz, Clinical Director, Alex Briceno Administrator, and Cindy Doutt Regional DirectorTIME COMPLETED:
02:55 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-20230213084818). The purpose of the visit is to issue citations for deficiencies observed during the complaint investigation.

During the complaint investigation of complaint #29-AS-20230213084818, the following deficiency was observed: Facility personnel complete records for Staff #1 (S1) were not available for the Community Care Licensing (CCL) Investigation Branch (IB) Investigator Santiago to inspect, audit and copy during the initial visit to the facility on 03/16/2023 and subsequent visit on 03/17/2023.

Facility also did not submit incident reports to CCL. On 2/14/23 LPA requested all incident reports related to the complaint and was given 4 incident reports dated 9/5/22, 9/7/22, 9/10/22 and 9/15/22. LPA reviewed incident reports sent to CCL and observed the last incident report the facility sent was received 5/4/21 dated 5/1/21 for a medication error. Administrator stated they didn't know they had to send them and asked where to send incident reports, LPA provided CCL's fax and email.

Citations issued, exit interview, copy of report, appeal rights were printed and emailed.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE: DATE: 05/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/30/2023
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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Document Has Been Signed on 05/30/2023 02:43 PM - It Cannot Be Edited


Created By: Jeannette Olson On 05/30/2023 at 07:34 AM
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 AGNES AVENUE
FACILITY NUMBER: 425802138

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/31/2023
Section Cited
CCR
80066(c)

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80066(c) Personnel Records All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours.

This requirement is not met as evidenced by:
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Administrator agreed to submit memo of understanding to CCL that personnel records will be readily available to the licensing agency at the facility when requested as specified in Section 80066(c) by 5/31/23.
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Based on observation and record review, the licensee did not comply with the section cited above when personnel complete records were not available for review and or copy during visits on 3/16/23 and 3/17/23, which posed a potential health and safety risk to residents in care.
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Type B
05/31/2023
Section Cited
CCR81061(b)

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81061(b) Reporting Requiements Upon the occurrence..a report shall be made to the licensing agency...a written report containing the information specified...shall be submitted to the licensing agency within seven days following the occurrence of such event.
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Administrator agreed to submit memo of understanding to CCL that incident reports need to be submitted to the licensing agency after 7 days as specified in Section 81061(b) by 5/31/23.
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Based on observation and record review, the licensee did not comply with the section cited above when incident reports were not submitted to licensing, which posed a potential health and safety risk to residents 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: 05/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2023


LIC809 (FAS) - (06/04)
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