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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200360
Report Date: 12/20/2023
Date Signed: 12/20/2023 04:18:15 PM

Document Has Been Signed on 12/20/2023 04:18 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:TELECARE HOPE HOUSEFACILITY NUMBER:
079200360
ADMINISTRATOR:GARCIA, DENISE GFACILITY TYPE:
772
ADDRESS:300 ILENE STREETTELEPHONE:
(925) 313-7980
CITY:MARTINEZSTATE: CAZIP CODE:
94553
CAPACITY: 16CENSUS: 14DATE:
12/20/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Janet McMiller, Office StaffTIME COMPLETED:
04:35 PM
NARRATIVE
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On 12/20/2023 at 2:30PM Licensing Program Analyst (LPA) Lori Alexander arrived unannounced to conduct a Case Management visit. LPA met with Janet McMiller. Janet phoned the Administrator, Clearnise Bullard to inform. LPA spoke with Clearnise over the phone during the visit. Clearnise advised that Lisa Domingo was authorized to sign documents.

While LPA L. Alexander was conducting a complaint investigation (15-AS-20231215164208) on 12/20/2023. During record review LPA observed C1’s file was missing documents. LPA requested court conservatorship document and discharge notes from the Administrator. The administrator stated that the documents were not accessible because she and the assigned clinician was not available at the facility to retrieve the documents.

The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided



SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE: DATE: 12/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2023
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 12/20/2023 04:18 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 12/20/2023 at 03:04 PM
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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: TELECARE HOPE HOUSE
FACILITY NUMBER: 079200360

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/22/2023
Section Cited
CCR
8007.0

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80070 Client Records
(d) All client records shall ...licensing agency to...copy upon demand during normal business hours.
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Administrator will submit a copy of C1's court appointed conservatorship document, all clinical/staff documented
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This requirement is not met as evidence by:

Based on file review and interview licensee did not comply with the section cited above by having records available during visit which poses an immediate health & safety risk for persons in care.
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discharge notes from 12/14/23 and care plan to CCLD by POC due date.
Type B
01/19/2024
Section Cited
CCR80061(a)(E)

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80061Reporting Requirements
(a) Each licensee...furnish to the licensing agency reports... (E) Any unusual incident...emotional health or safety of any client.
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Administrator agreed to read the regulation and self-certify that they read/understand the regulation moving forward. Administrator will have a
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This requirement is not met as evidence by:

Based on record review and interview licensee did not comply with the section cited above by not reporting Licensing unusual incidents which poses an immediate health & safety risk for persons in care.
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in-house training with staff. Administrator will send a copy of signatures of all staff attendees to CCLD by POC due date.
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:Bennett Fong
LICENSING EVALUATOR NAME:Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2023


LIC809 (FAS) - (06/04)
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