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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201018
Report Date: 09/15/2022
Date Signed: 09/15/2022 12:14:24 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/12/2022 and conducted by Evaluator Laura Hall
COMPLAINT CONTROL NUMBER: 15-AS-20220912085201
FACILITY NAME:TELECARE HILLSIDE HOUSEFACILITY NUMBER:
079201018
ADMINISTRATOR:STACI L. STEVENSFACILITY TYPE:
737
ADDRESS:205 HILLSIDE ROADTELEPHONE:
(925) 433-0577
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY:4CENSUS: 4DATE:
09/15/2022
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Staci Stevens, AdministratorTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Facility not providing adequate supervision to accommodate clients service plans
INVESTIGATION FINDINGS:
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On 9/14/2022 at 11:15AM, Licensing Program Analyst (LPA), L. Hall arrived unannounced conduct a complaint investigation and to deliver complaint findings for the allegation above. LPA met with Staaci Stevens, Administrator and explained the reason for the visit.

During the investigation LPA interviewed S1, reviewed and obtained the IBSP (Individual Behavior Support Plan) for C1, C2, C3, and C4. During interview with S1 it was stated that at this time the facility does not have sufficient staffing. S1 stated facility is in process of hiring staff.

Continued on LIC809C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 15-AS-20220912085201
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: TELECARE HILLSIDE HOUSE
FACILITY NUMBER: 079201018
VISIT DATE: 09/15/2022
NARRATIVE
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Continued from LIC809.

Based on LPA interview which was conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20220912085201
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: TELECARE HILLSIDE HOUSE
FACILITY NUMBER: 079201018
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/22/2022
Section Cited
CCR
80065(a)
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80065 Personnel Requirements (a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs. This requirement was not met as evidence by:
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Administrator agreed to submit four (4) LIC9182's to show facility is in process of hiring by POC date and will submit an updated LIC500 by 10/27/2022 to CCLD.
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Based on LPA's observation and record review the Licensee did not comply with the section cited above by having sufficient staff employed, which poses a potential health and safety risk to persons 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.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3