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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201018
Report Date: 12/29/2022
Date Signed: 12/29/2022 12:57:02 PM

Document Has Been Signed on 12/29/2022 12:57 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:STACI L. STEVENSFACILITY TYPE:
737
ADDRESS:205 HILLSIDE ROADTELEPHONE:
(925) 433-0577
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 4CENSUS: 4DATE:
12/29/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Mary Thrower, Vice President of OperationsTIME COMPLETED:
01:00 PM
NARRATIVE
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On 12/29/2022 at 12:05PM Licensing Program Analysts (LPAs) L. Hall and L. Alexander arrived unannounced to conduct a Case Management visit. LPAs met with Mary Thrower, Vice President of Operations.

When LPA L. Hall was conducting a complaint investigation (15-AS-20221115153204) on 11/17/2022, LPA requested the investigation documentation from Staff 2 (S2). S2 stated that he will request documentation from the Human Resources Department, and it will be emailed to LPA. S2 included LPA on email that was sent to the Human Resources Department requesting documentation. On 11/29/2022 LPA replied to email stating that the documentation has not been received. As of today’s, date the documentation has not been received.

The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties.



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: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/29/2022
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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Document Has Been Signed on 12/29/2022 12:57 PM - It Cannot Be Edited


Created By: Laura Hall On 12/29/2022 at 12:20 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: 12/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/13/2023
Section Cited
CCR
80044(c)

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80044 (c) The licensing agency shall have the authority to inspect, audit, and copy client or facility records upon demand during normal business hours.
This requirement was not met as evidence by:
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Vice President agreed to have an in-house training on regulation 80044, submit a staff sign-in sheet, and submit investigation documents to CCLD by POC date.
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Based on LPA's observation and record review the Licensee did not comply with the section cited above in providing documentation to CCLD, which poses a potential health and safety risk for 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.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 12/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/29/2022


LIC809 (FAS) - (06/04)
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