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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455002679
Report Date: 12/16/2021
Date Signed: 12/16/2021 01:13:13 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:HALLMARK HOUSEFACILITY NUMBER:
455002679
ADMINISTRATOR:MYERS, BRENDAFACILITY TYPE:
740
ADDRESS:935 HALLMARK DRTELEPHONE:
(530) 605-4041
CITY:REDDINGSTATE: CAZIP CODE:
96001
CAPACITY:6CENSUS: 5DATE:
12/16/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Maria Teibel, Direct Care Staff TIME COMPLETED:
02:30 PM
NARRATIVE
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On 12/16//2021, Licensing Program Analyst (LPA) Misty Valencia conducted an announced case management investigation visit regarding medication errors. LPA met with Maria Teibel, Direct Care Staff and explained the reason for the visit. Prior to initiating the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted Administrator and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical masks. Additionally, LPA was screened by staff at the front door.

LPA explained to Ms. Teibel that while LPA was investigating complaint #25-AS-20211008112012 and reviewing records, LPA observed that R1 had a missed medication error on R1's Medication Administration Record (MARS).

The following deficiencies were observed at today’s visit (see LIC 809D ) and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted, report copy was emailed to Licensee, and appeal rights provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Misty ValenciaTELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2021
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, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: HALLMARK HOUSE
FACILITY NUMBER: 455002679
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/16/2021
Section Cited

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Incidental Medical and Dental Care Services 87465(a)(5). The licensee shall assist residents with self-administered medications when needed. This requirement is not met as evidenced by:
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licensee did not ensure that staff provided R1's medication as prescribed by a physician. This posed an immediate health and safety risk to residents in care.
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Licensee will send to CCL a written plan for training and scheduling to show training; shadowing and successful med passes before all staff are to be working alone by 12/17/2021.

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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: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Misty ValenciaTELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2021
LIC809 (FAS) - (06/04)
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