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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 02:13:24 PM

Document Has Been Signed on 01/31/2025 02:13 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:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Nicolas Dedicatoria, LeadTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
NARRATIVE
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On 1/31/2025 at 1:15pm, Licensing Program Analyst (LPA) L. Hall conducted an unannounced Case Management visit regarding an incident that was reported to CCLD on 1/10/2025. LPA met with Nicolas, Dedicatoria, Lead and explained the purpose of the visit.

The incident reported occurred on 1/09/2025. The report stated S1 was conducting a count of the medication and observed there were two (2) missing pills that belonged to C1. S1 reviewed verification checklist and observed three (3) pills were dispensed. S2 confirmed three (3) pills were given instead of one (1).

While conducting the case management visit LPA was informed another incident regarding mismanaging of medication occurred this morning. LPA interviewed three (3) staff. Two (2) of the three (3) was involved in the incident. S2 stated the 7 rights was completed and the medication was given to S3 to verify. S3 verified but gave medication to C2. Medication belonged to C1. S3 stated she verified the medication and assumed it was for C2 because C2 was her assignment. C2's doctor was contacted and was told to bring C1 to Sutter Delta Medical Center.

LPA obtained the after-summary visit for C2.

*An immediate $250.00 civil penalty will be assessed on today's date for repeat deficiency*

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
NARRATIVE
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Continued from LIC809.

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, LIC421FC 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 02:13 PM - It Cannot Be Edited


Created By: Laura Hall On 01/31/2025 at 01:49 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
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/01/2025
Section Cited
CCR
80075(b)

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80075 Health Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.
This requirement was not met as evidence by:
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Administrator agreed to implement a plan by on boarding a skilled professional to assist with medication and submit plan to CCLD by POC date.
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Based on record review and interview the Licensee did not comply with the section cited above in administering medication as prescribed, 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.
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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