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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201018
Report Date: 08/29/2024
Date Signed: 08/29/2024 11:48:46 AM

Document Has Been Signed on 08/29/2024 11:48 AM - 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/
DIRECTOR:		OLIVES, ADAM JFACILITY TYPE:
737
ADDRESS:205 HILLSIDE ROADTELEPHONE:
(925) 433-0577
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 4CENSUS: 4DATE:
08/29/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:55 AM
MET WITH:Dejah Jordan, Lead Direct Support ProfessionalTIME VISIT/
INSPECTION COMPLETED:
11:55 AM
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On 8/29/2024, at 10:55am, Licensing Program Analyst (LPA) L. Hall conducted an unannounced Case Management visit regarding an incident that was reported to CCLD on 8/15/2024. LPA met with Dejah Jordan, Lead Direct Support Professional and explained the purpose of the visit. LPA spoke with Adam Olives, Administrator, via telephone.

The incident report occurred on 8/13/2024 regarding missed medication for C1. S1 did not give C1 the morning medication and S2 found the error that night. The facility has now implemented a policy where there will be a 2-way verification on passing the medication, verification of the medication administrative record (MAR), and verification of the medication verification staff checklist and cup. LPA obtained a copy of the medication verification staff checklist also called the 7 rights to administer medication.

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: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2024
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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