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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201018
Report Date: 01/31/2025
Date Signed: 01/31/2025 01:13:19 PM

Document Has Been Signed on 01/31/2025 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/
DIRECTOR:		MENDENHALL, JESSEFACILITY TYPE:
737
ADDRESS:205 HILLSIDE ROADTELEPHONE:
(925) 433-0577
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 4CENSUS: 4DATE:
01/31/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Adam Olives, Regional Director of OperationsTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
NARRATIVE
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On 1/31/2025 at 10:00AM, Licensing Program Analyst (LPA) L. Hall conducted an unannounced annual inspection. LPA met with Adam Olives Regional Director of Operations at 10:25am, and explained the purpose of the visit. LPA spoke with Administrator, Jesse Mendenhall via telephone. Administrator currently holds a certificate (#7026751735) that expires on 11/16/2025. The facility’s fire clearance was approved for four (4) non-ambulatory clients.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of four (4) total bedrooms and two (2) bathrooms. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 73 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 115.2 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. Hand washing poster, paper towel, and soap observed at all hand washing stations. The supply of extra hygiene was available for residents. There is a minimum of 7-day non-perishables and 2-day perishables foods.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 01/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/31/2025
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: 01/31/2025
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Continued from LIC809.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 5/24/2024. Emergency Disaster Plan was last updated on 07/1/2023. First aid kit was observed to be complete. Fire drill was last conducted on 11/20/2024.

LPA reviewed four (4) staff files all are current. Two (2) additional staff were from the registry. All four (4) clients records reviewed and current and complete. LPA also reviewed P & I and a sample of medication.

The following forms to be updated and submitted to CCLD by 02/7/2025:
  • LIC 500 Personnel Report
  • LIC 400 Affidavit Regarding Client/Resident Cash Resources
  • LIC 402 Surety Bond
  • LIC 610D Emergency disaster plan (last page)
  • At 11:50am LPA observed during record review the Administrator file was not available for review


The deficiency is cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

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

DATE: 01/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/31/2025 01:13 PM - It Cannot Be Edited


Created By: Laura Hall On 01/31/2025 at 12:59 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 HILLSIDE HOUSE
FACILITY NUMBER: 079201018

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(c)
80066 Personnel Records

(c) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. removal of records shall be subject to the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in having the administrator file available for review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/07/2025
Plan of Correction
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Administrator agreed to review regulation 80066, agreed to abide by regulation going forward, and submit a self-certification to CCLD by POC date
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2025


LIC809 (FAS) - (06/04)
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