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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803851
Report Date: 04/11/2024
Date Signed: 04/11/2024 01:09:27 PM

Document Has Been Signed on 04/11/2024 01:09 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:TELECARE BECK LANEFACILITY NUMBER:
486803851
ADMINISTRATOR/
DIRECTOR:
JENNINGS, MONTELFACILITY TYPE:
738
ADDRESS:4500 BECK LANETELEPHONE:
(707) 299-9041
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY: 4CENSUS: 4DATE:
04/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:47 AM
MET WITH:Montel Jennings, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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On 4/11/2024, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. Inspection for this facility and was greeted by Administrator, Montel Jennings and Staff, Justine Reja. The facility currently provides care for 4 clients, two of which were present at the time of visit. LPA continued with a tour of the facility with staff. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers were found to be last charged on 7/26/2023. Smoke and carbon monoxide detectors were interconnected found throughout the facility, tested and to be in working order. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were stored properly as per regulations on this day at the time of the visit. Water at faucets accessible to clients were measured between 112.2 and 119.8 degrees F which is within Title 22 Regulations. Facility conducts and records emergency disaster drills once per month.

Medications are located in a designated cabinet shared with the laundry room and found to be secured. A spot medication count was conducted for client and found to be in order. LPA observed missing start dates on a client's centrally stored medication records, Technical Violation Issued. Medication administration records were also reviewed and found to be in order. LPA conducted a review for staff files and found all staff to have 1st Aid & CPR certification and annual training on file. In addition, LPA reviewed client record and found all documents including North Bay Regional Center Individual Program Plans and Physician's Reports to be current. There is a sufficient supply of linens, hygiene product and paper products available for client use. Items that could pose danger to client if accessible were found to be secured. Facility van was inspected and found to have appropriate emergency safety items including first aid kit and fire extinguisher. Clients were observed to have a positive relationship with staff and found participating in activities or meetings during the visit.

Continued onto LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/11/2024
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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: TELECARE BECK LANE
FACILITY NUMBER: 486803851
VISIT DATE: 04/11/2024
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In addition, LPA conducted a follow up on recommendations during a previous visit from North Bay Regional Center including, renovation in the kitchen. Upon inspection, LPA found the kitchen minor restorations are in the process of completion. All other items have been addressed:

- Sharps to be secured
- Toiletry items available for client use
- Restroom kept clean, safe and sanitary
- General cleaning of kitchen area


LPA requested the following documents be sent to CCL by COB 5/11/2024:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Liability Insurance
Proof of ownership/Control of Property

No deficiencies cited during today's visit.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024
LIC809 (FAS) - (06/04)
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