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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803851
Report Date: 10/14/2021
Date Signed: 10/14/2021 12:21:22 PM

Document Has Been Signed on 10/14/2021 12:21 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:TELECARE BECK LANEFACILITY NUMBER:
486803851
ADMINISTRATOR:MONTEL JENNINGSFACILITY TYPE:
738
ADDRESS:4500 BECK LANETELEPHONE:
(707) 880-3254
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY: 4CENSUS: 3DATE:
10/14/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Montel Jennings, AdmnistratorTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Lopez conducted an unannounced case management inspection and met with Administrator, Montel Jennings. The purpose of the case management inspection was to obtain additional information regarding a self reported incident submitted to Community Care Licensing (CCL) on 9/22/21.

CCL received an incident report reporting a medication error. S1 was preparing the dispensing of medications using the Medication Administration Record (MAR) to identify the correct medication was dispensed for clients. S2 verified the medications and noticed that there a possible incorrect dosage of medication for C1. S2 was unsure of a medication change and advised S1. S1 was going to check on the medication change but was then distracted by issues involving a client. S1 then forgot to check on the change of medication resulting in medication error for C1. Facility removed S1 from dealing with medications until further training. C1's doctor and parents were notified. LPA was given copies of records indicating medication error, C1's Physician report, S1's Employee Coaching Notes and S1's proof of training documentation during today's case management inspection.

Appeal Rights Provided.
Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiencies and/or repeat deficiencies within a 12 month period may result in civil penalties.
Exit interview conducted with Administrator, Montel Jennings whose signature below confirms receipt of report.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Karen Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2021
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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Document Has Been Signed on 10/14/2021 12:21 PM - It Cannot Be Edited


Created By: Karen Lopez On 10/14/2021 at 11:31 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: 10/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/14/2021
Section Cited
CCR
80075(b)

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80075 Health Related Services(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

**This requirement is not met as evidenced by:
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CItation cleared during inspection. Facility conducted staff training with S1 on 9/29/21. Proof of training documentation was given to LPA at time of visit.
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Based on record review and converstation with Admnistrator facility failed to ensure C1's medication was given as prescribed by doctor which poses an immediate health and safety risk to Client 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:Bethany Moellers
LICENSING EVALUATOR NAME:Karen Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2021


LIC809 (FAS) - (06/04)
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