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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803851
Report Date: 04/20/2022
Date Signed: 04/20/2022 11:36:58 AM

Document Has Been Signed on 04/20/2022 11:36 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:
04/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:14 AM
MET WITH:Administrator, Montel JenningsTIME COMPLETED:
11:46 AM
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At approximately 10:00AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct an Annual Inspection visit and was greeted by Administrator, Montel Jennings. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival at the facility, LPA had their temperature checked and logged. LPA answered a standard COVID-symptom questionnaire. LPA conducted a walk-through of the facility and observed the following: Hand-washing signs were observed in the bathrooms and at sinks, and reminders to wear masks. Per conversation with Administrator, the facility limits the amount of Covid-19 signs due to client behaviors. All staff present were observed to be wearing a mask. The facility was found to be clean and at a comfortable temperature with all exits free from obstruction.

Facility has a cleaning and disinfecting schedule that occurs every hour. Facility has at least a 30-day supply of Personal Protective Equipment (PPE) and medication for clients. Staff and Clients are screened daily for COVID-19 symptoms and it is logged into facility binders.

LPA and Administrator discussed N-95 Fit testing, activities, and PPE. Facility has a plan in place if a staffing shortage were to occur.

Continued on LIC 809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 04/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/20/2022
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: 04/20/2022
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Continued from LIC 809-C

Fire extinguishers were last serviced October 2021. Fire alarm and Carbon Monoxide detectors were not tested due to possible client behaviors. Administrator stated that systems were tested last month.

LPA and Administrator discussed some recent SIRs/SOC341s regarding C1 and C2. Per conversation with Administrator, C1 is anxious about moving to their new placement. C1's new placement was delayed. Facility has weekly meetings to discuss C1 and how to assist with de-escalating their behaviors. Administrator stated that C1 has made great progress in using their coping skills and that staff remind C2 about C1's behavioral triggers. Staffing ratio for C1 and C2 are 1.5 staff members.

LPA observed part of the flooring in the facility that needs repairs. Damaged flooring was observed to not be a safety hazard for Clients. Per conversation with Administrator, they had notified their Corporation about the repairs a year ago and it is on the list to be repaired.

LPA requested the following records by Close of Business on Friday, 4/22/2022:

- Updated Personnel Report (LIC 500)
- Copy of Surety Bond (LIC 402)
- Documentation stating that Facility had their fire alarm and Carbon Monoxide detectors tested


No Deficiencies cited during this inspection.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2022
LIC809 (FAS) - (06/04)
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