425802138-10-3-2023-29-AS-JOLN-CWA2EC-20231003171944

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425802138
Report Date: 10/03/2023
Date Signed: 10/03/2023 05:19:59 PM

Document Has Been Signed on 10/03/2023 05:19 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 AVENUE		FACILITY NUMBER:	425802138
ADMINISTRATOR:	JESSICA GEIHS		FACILITY TYPE:	772
ADDRESS:	116 AGNES AVENUE		TELEPHONE:	(805) 457-3724
CITY:	SANTA MARIA	STATE: CA	ZIP CODE:	93458
CAPACITY: 10		CENSUS: 8	DATE:	10/03/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Jessica Geihs, Administrator and Mark Taylor, Team Lead		TIME COMPLETED:	05:55 PM

NARRATIVE

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Licensing Program Analyst (LPA) Jenny Olson arrived at the facility unannounced to conduct a required annual visit at 10:20 a.m. LPA met with Jessica Geihs Administrator and Mark Taylor, Team Lead 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. Carbon monoxide detector were tested and operational at the time of the visit. The fire extinguisher was charged and serviced 9/5/2023.

The outside area is equipped with furniture for client use. LPA recommended facility get shade like an umbrella. No bodies of water noted. The washer and dryer are in a laundry room which is unlocked and has extra linens.

Restrooms: The two client restrooms were clean and sanitary and in operating condition. The bathrooms were sufficiently stocked with soap and paper towels. Around 3:15 p.m., the hot water temperature measured in the kitchen at 124.5 degrees Fahrenheit.

Bedrooms: There are five (5) client rooms, which were furnished appropriately.

Records: LPA reviewed client records at 10:30 a.m. LPA reviewed five (5) client 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.

Continued on 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023

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 AGNES AVENUE	FACILITY NUMBER: 425802138
	VISIT DATE: 10/03/2023

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INFECTION CONTROL: Signs were posted that promotes good hand hygiene and symptoms of COVIDt. 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 dusting protocol needs improvement. 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.

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

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/03/2023 05:19 PM - It Cannot Be Edited

Created By: Jeannette Olson On 10/03/2023 at 05:06 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 AGNES AVENUE	FACILITY NUMBER: 425802138
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

81088(e)(1)

Fixtures, Furniture, Equipment, and Supplies

(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in the water measured at 124.5 degrees which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/04/2023
	Plan of Correction
1 2 3 4	Administrator immediately called the county to lower the water tempurature. Administrator agreed to send LPA a video of the water at the correct temperature.

Section Cited


	Deficient Practice Statement
1 2 3 4
	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.

SUPERVISOR'S NAME:

Kelly Burley

LICENSING EVALUATOR NAME:

Jeannette Olson

LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023

LIC809 (FAS) - (06/04)

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