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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 02:01:42 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
06/09/2022 and conducted by Evaluator Laura Hall
COMPLAINT CONTROL NUMBER: 15-AS-20220609084330
FACILITY NAME:TELECARE HILLSIDE HOUSEFACILITY NUMBER:
079201018
ADMINISTRATOR:ROSEMARY ENDICKFACILITY TYPE:
737
ADDRESS:205 HILLSIDE ROADTELEPHONE:
(925) 433-0577
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY:4CENSUS: 4DATE:
09/15/2022
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Staci Stevens, AdministratorTIME COMPLETED:
02:10 PM
ALLEGATION(S):
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Staff handles residents in a rough manor
INVESTIGATION FINDINGS:
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On 9/15/2022 at 12:15PM, Licensing Program Analyst (LPA), L. Hall arrived unannounced conduct a complaint investigation and to deliver complaint findings for the allegation above. LPA met with Staci Stevens, Administrator and explained the reason for the visit.

During the course of the investigation, LPA interviewed seven (7) staff, three (3) clients, reviewed and obtained records. On the allegation staff handles residents in a rough manner, during interviews five (5) out of the (7) staff stated that C1 was handled in a rough manner during an incident dated 6/8/2022. C1 stated during interview that S2 is mean to him sometimes. Therefore, the allegation is substantiated.

Continued on LIC9099C.
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 5
Control Number 15-AS-20220609084330
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 LIC9099.

Based on LPA interviews which were 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 LIC9099D.

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 5
Control Number 15-AS-20220609084330
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
80072(a)(3)
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80072 Personal Rights
(a) ... each client shall have personal rights which include, but are not limited to, the following: (3) To be free from...punishment, infliction of pain, humiliation, intimidation... threat, mental abuse... physical functioning.
This requirement was not met as evidence by:
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 Administrator agreed to have an authorized vendor provide training for all staff on personal rights. Licensee will schedule training by 9/22/2022 and submit proof of completion by 10/21/2022.
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Based on LPA's interviews the Licensee did not comply with the section cited above in having clients physical function protected, 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 5
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
06/09/2022 and conducted by Evaluator Laura Hall
COMPLAINT CONTROL NUMBER: 15-AS-20220609084330

FACILITY NAME:TELECARE HILLSIDE HOUSEFACILITY NUMBER:
079201018
ADMINISTRATOR:ROSEMARY ENDICKFACILITY TYPE:
737
ADDRESS:205 HILLSIDE ROADTELEPHONE:
(925) 433-0577
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY:4CENSUS: 4DATE:
09/15/2022
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Staci Stevens, AdministratorTIME COMPLETED:
02:10 PM
ALLEGATION(S):
1
2
3
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5
6
7
8
9
Staff hit resident

Staff kicked resident

Staff are not properly trained
INVESTIGATION FINDINGS:
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On 9/15/2022 at 12:15PM, Licensing Program Analyst (LPA), L. Hall arrived unannounced conduct a complaint investigation and to deliver complaint findings for the allegation above. LPA met with Staci Stevens, Administrator and explained the reason for the visit.

During the course of the investigation, LPA interviewed seven (7) staff, three (3) clients, reviewed and obtained records. Based on the allegations staff hit resident and staff kicked resident. None of the clients stated during interviews that they have been hit or kicked by any staff or have seen another client hit or kicked by any staff. During record review LPA did not observe any disciplinary actions taken against staff for mistreatment of clients. Therefore, both allegations are unsubstantiated.

Continued on LIC9099C.
Unsubstantiated
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: 4 of 5
Control Number 15-AS-20220609084330
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 LIC9099.

Based on the allegation staff are not properly trained. LPA reviewed seven (7) employee files. Three (3) of the seven (7) employees all were current on their RBT (Register Behavior Technician) training. Two (2) of those three (3) have been employed under a year, and the other one (1) is not required to have RBT. All seven (7) employees are up-to-date with their CPI (Crisis Prevention Institute) training.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted and a copy of this report 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: 5 of 5