079201018-10-9-2023-15-AS-LHAL-CWFR5N-20231009124326

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079201018
Report Date: 10/09/2023
Date Signed: 10/09/2023 12:43:37 PM

Document Has Been Signed on 10/09/2023 12:43 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 HOUSE		FACILITY NUMBER:	079201018
ADMINISTRATOR:	TIFFANY SPIECKER		FACILITY TYPE:	737
ADDRESS:	205 HILLSIDE ROAD		TELEPHONE:	(925) 433-0577
CITY:	ANTIOCH	STATE: CA	ZIP CODE:	94509
CAPACITY: 4		CENSUS: 4	DATE:	10/09/2023
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Adam Olives, Administrator		TIME COMPLETED:	12:50 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 10/09/2023 at 12:15pm,, Licensing Program Analyst (LPA) conducted case management visit as a follow-up to a substantiated allegations of physical abuse/improper restraints and personal rights. LPA met with Adam Olives, Administrator and explained the purpose of the visit. On July 5, 2023, the Department concluded a complaint investigation and substantiated an allegation that staff are mishandling a client (C1) while in restraints. It was also substantiated that staff are mistreating C1 while in care. This complaint was received on November 15, 2022. The Department determined at the conclusion of the complaint investigation that the facility had used inappropriate restraint techniques that may have caused physical injury to the client. Per after summary visit from the emergency department dated October 23, 2022, C1 had sustained an injury to his sternum and the cause of the injury could have occurred from direct force to the sternum or a flexing (bending) injury. It was also determined based on witnesses’ statements from the facility that staff S3 and S4 used inappropriate restraint techniques that may have caused physical injury and/or emotional distress. Continued on LIC809C.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2023

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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: TELECARE HILLSIDE HOUSE	FACILITY NUMBER: 079201018
	VISIT DATE: 10/09/2023

NARRATIVE

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Continued from LIC809.

The Licensee was cited for violating California Code of Regulations (CCR) Title 22 § 80072(a)(3) – Personal Rights, which states in part that “(a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with the daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning.” In addition, the Licensee was cited for violating California Code of Regulations (CCR) Title 22 § 80072(a)(1) Personnel Rights, which states in part that “(a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following:” (1) To be accorded dignity in his/her personal relationships with staff and other persons.

On October 20, 2022, C1 was placed in a restraint twice on the same day by S3 and S4. A witness of the incident stated that C1’s wrist being bent all the way down (demonstrated) and S3 took C1’s head and shoved it down between C1’s legs (demonstrated). On October 23, 2023, it was noted that C1 complained of pain to the chest and was taken to the hospital and was found to have sustained an injury to the sternum. A witness stated there was a previous incident (unknown date) it was observed where S3 and (S4) had C1’s arms pulled back, put pressure on C1’s back, and put C1’s head between his legs. The witness stated C1 was grasping for air

Continued on LIC809C.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2023

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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: TELECARE HILLSIDE HOUSE	FACILITY NUMBER: 079201018
	VISIT DATE: 10/09/2023

NARRATIVE

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Continued from LIC809C.

Based on interviews and records reviewed by the Department, it was determined that C1 was inappropriately mishandled and mistreated while in care, resulting in C1 sustaining an injury.

At the time of the Complaint investigation visit, an immediate civil penalty of $500.00 was issued. The issuance of an additional civil penalty was still being determined and the licensee was informed that an additional civil penalty might be assessed. The Department has concluded an analysis and has determined that a civil penalty is warranted. Today, (Date), the Department will be issuing a civil penalty in the amount of $10,000.00 per California Health and Safety Code §1548(f)(1)(A) for a violation the Department determined resulted in injury of C1. However, since an immediate civil penalty of $500.00 was previously issued on February 21, 2023, the amount of the civil penalty issued today will be $9,500.00.

Exit interview conducted. A copy of the appeal rights, the LIC421D, and this report were provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2023

LIC809 (FAS) - (06/04)

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