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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201018
Report Date: 08/11/2023
Date Signed: 08/11/2023 01:13:19 PM

Document Has Been Signed on 08/11/2023 01:13 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:TELECARE HILLSIDE HOUSEFACILITY NUMBER:
079201018
ADMINISTRATOR:TIFFANY SPIECKERFACILITY TYPE:
737
ADDRESS:205 HILLSIDE ROADTELEPHONE:
(925) 433-0577
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 4CENSUS: 4DATE:
08/11/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Adam Olives, AdministratorTIME COMPLETED:
01:20 PM
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On 8/11/2023 at 12:05pm, Licensing Program Analyst (LPA) L. Hall conducted an unannounced Case Management visit regarding an incident that was reported to CCLD on 8/4/2023. LPA met with Adam Olives, Administrator and explained the purpose of the visit.

Review of incident report indicates the incident occurred on 8/2/2023. C1 made allegations toward three (3) staff members. The facility conducted an internal investigation for the allegations. The first allegation that involved S2 allegedly occurred in March 2023 the facility didn't have any time frame of when the other 2 allegations took place. Record review indicated S4 self reported incident to facility on a descriptive assessment: ABC data. Record review and internal interview for the second allegation that involved S5 indicated S5 was never involved in a car hold scenario. The facility did not directly interview S6 regarding the allegation. The facility interviewed C1 and stated C1's story changed a few times. C1 stated during interview with LPA that S4 punched him but was not able to give date. C1 mention there was an incident on Sunday with a staff, but that staff was not working on Sunday. C1 did not mention any other incidents that occurred.

LPA L. Hall collected investigation summary and descriptive assessment: ABC data.

No deficiencies issued during the visit.

Exit interview conducted and a copy of this report was provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 08/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/11/2023
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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