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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803851
Report Date: 05/04/2023
Date Signed: 05/04/2023 10:30:48 AM

Document Has Been Signed on 05/04/2023 10:30 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:TELECARE BECK LANEFACILITY NUMBER:
486803851
ADMINISTRATOR:JENNINGS, MONTELFACILITY TYPE:
738
ADDRESS:4500 BECK LANETELEPHONE:
(707) 299-9041
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY: 4CENSUS: 4DATE:
05/04/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator, Montel JenningsTIME COMPLETED:
10:30 AM
NARRATIVE
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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 on an incident report that was self-reported by the facility regarding an Elopement from Client #1. During the incident dated for April 13, 2023, Staff Member was preoccupied with assisting another client when Client #1 eloped and was walking back with a neighbor. Client repopulated back into the community and facility initiated an elopement procedure as well as documenting the incident on a Special Incident Report (SIR). Administrator disclosed that Client is not supposed to be out in the community unassisted. LPA requested the following documents to be reviewed today:

-LIC 602
-Care Plan

During a review of the LIC 602 and Care Plan, LPA learned via observation that the Client is not supposed to be leaving the facility unassisted. Furthermore, Client should be on a 2 to 1 observation by staff members. LPA attempted to interview Client #1, but was unsuccessful. LPA toured the facility and found the facility to be clean, and at a comfortable temperature with all exits free from obstruction.

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 and a copy of this report was given to the Administrator.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/04/2023
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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Document Has Been Signed on 05/04/2023 10:30 AM - It Cannot Be Edited


Created By: Farhaan Sarangi On 05/04/2023 at 10:11 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: TELECARE BECK LANE
FACILITY NUMBER: 486803851

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/05/2023
Section Cited
CCR
80078(a)

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80078 Responsibility for Providing Care and Supervision:

(a) The licensee shall provide care and supervision as necessary to meet the client's needs.
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Plan of Correction shall be to ensure that staff training is conducted with all staff members. Furthermore, a plan for future compliance shall be documented and sent to the LPA.
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This requirement was not met as evidenced by:

Based on record review and interview, facility staff did not comply with this section. Client #1 eloped from the facility. Client #1 required a 2:1 staffing and could not be in the community unsupervised which posed an immediate health and safety risk to client in care.
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Plan of Correction as it relates to the training shall be conducted by May 11, 2023.

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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:Hope DeBenedetti
LICENSING EVALUATOR NAME:Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2023


LIC809 (FAS) - (06/04)
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