<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803851
Report Date: 12/15/2021
Date Signed: 12/15/2021 11:02:58 AM

Document Has Been Signed on 12/15/2021 11:02 AM - 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:TELECARE BECK LANEFACILITY NUMBER:
486803851
ADMINISTRATOR:RFACILITY TYPE:
738
ADDRESS:4500 BECK LANETELEPHONE:
(707) 299-9041
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY: 4CENSUS: 3DATE:
12/15/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Administrator, Montel JenningsTIME COMPLETED:
11:00 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Telecare Beck Lane for the purpose of conducting a Case Management-Incident inspection. LPA was greeted at the door by Administrator, Montel Jennings and was granted access into the facility.

LPA is following up regarding an incident that was self-reported by the facility for a medication error. Facility reported a medication error on 11/27/2021 for client, C1 where a medication was not given and the incident report was dated for 11/29/2021. Error was found during an audit of the Medication Assessment Record (MAR). Client did not have any adverse effects from missing medication. LPA requested a copy of the Medication Assessment Record (MAR) for 11/27/2021, staff schedule and the Counseling Conference Record for Staff #1 (S1). LPA issued an 9102, Technical Violation for two staff members missing training hours.

A Civil Penalty in the amount of $250.00 is being assessed due to a repeat violation of the same regulation in a 12-month period. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview was conducted and a copy of this report along with the appeal rights were given to Administrator, Montel Jennings.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
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)
Page: 1 of 2
Document Has Been Signed on 12/15/2021 11:02 AM - It Cannot Be Edited


Created By: Farhaan Sarangi On 12/15/2021 at 09:49 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
, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: TELECARE BECK LANE
FACILITY NUMBER: 486803851

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/15/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/16/2021
Section Cited
CCR
80075(b)

1
2
3
4
5
6
7
80075 Health Related Services (b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Facility will conduct medication management training for all staff by 12/22/2021 and provide proof on how this regulation will be followed moving forward.
8
9
10
11
12
13
14
Based on document review and interview, C1 was not given their medication on 11/27/2021. This is an immediate health and safety risk to clients in care.
8
9
10
11
12
13
14
A Civil Penalty in the amount of $250.00 is being assessed due to a repeat violation of the same regulation in a 12 month period.

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Hope DeBenedetti
LICENSING EVALUATOR NAME:Farhaan Sarangi
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)
Page: 2 of 2