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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803851
Report Date: 04/17/2023
Date Signed: 04/17/2023 01:58:20 PM

Document Has Been Signed on 04/17/2023 01:58 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:JENNINGS, MONTELFACILITY TYPE:
738
ADDRESS:4500 BECK LANETELEPHONE:
(707) 299-9041
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY: 4CENSUS: 4DATE:
04/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Lead RBT, Aujenae MooreTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Telecare Beck Lane for the purpose of conducting a Required 1 year inspection. LPA was greeted at the door by Lead RBT, Aujenae Moore, and was granted access into the facility. Client census is 4 with 2 clients being at their respective Adult Day Programs. Administrator, Montel Jennings arrived 30 minutes later.

LPA and Lead RBT toured the facility. LPA observed the facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguishers were found to be last charged on October 2022 at the time of the inspection. All smoke detectors and carbon monoxide detectors are tested yearly and sound directly to the fire station. First Aid kit was inspected and found to be appropriate. Water temperature in 2 of 2 clients bathrooms measured at 118 degrees, within acceptable range of 105 to 120 degrees F. There was sufficient perishable and non-perishable foods located in the kitchen. There are special provisions made for individuals with special dietary needs. Food menu was presently available for viewing during the inspection. Medications were centrally stored and locked. Medication Assessment Records (MARS) for clients in care were inspected and found to be appropriate during the client file reviews. Cleaning products and other toxins are located in the laundry room that was locked and inaccessible to clients in care. There was a supply of Linens, cleaners, hygiene products and paper products available for clients. All bathrooms designated for clients in the common areas at the facility were supplied with individual paper towels and hand soap. Bathrooms in clients rooms have a towel and soap. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. A tour of all clients bedrooms were conducted, and bedrooms inspected have lighting and appropriate furnishings. LPA discussed the Infection Control Plan with the Administrator and Administrator to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Facility has sufficient Personal Protective Equipment (PPE). Staff at the facility have been N95 Fit tested in June of 2022. Emergency Disaster Plan was discussed and reviewed with the Administrator of the facility. (Report continued on LIC 809C)
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 04/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/17/2023
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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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: 04/17/2023
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LPA conducted staff interviews with five (5) staff members. LPA interviewed 2 out of the 4 clients. Remainder of clients were at their respective Adult Day Programs. LPA reviewed client files during the Required 1 year inspection, and found that 1 out of 4 clients did not have an updated LIC 602 retained in the file (See LIC 9102-Technical Advisory). Administrator was educated regarding the importance of retaining such documents in client files. Staff records were reviewed during the Required 1 year inspection. During the staff file review, LPA observed that a staff member did not have the training documents retained in the file (See LIC 9102-Technical Advisory).

LPA requested the following documents to be sent:

LIC 500- Personnel Report
LIC 308- Designation of Responsibility
LIC 309- Administrative Organization
LIC 400- Affidavit regarding Client Cash Resources
Updated facility sketch
Updated Emergency Disaster Plan (LIC 610)
Surety Bond
Most up-to-date Liability insurance
Control of Property
Register of residents
Fire Alarm System Inspection Test

No deficiencies were cited during today's Required 1 year inspection. Exit interview was conducted and a copy of this report was given to the facility Administrator.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2023
LIC809 (FAS) - (06/04)
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