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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201018
Report Date: 04/21/2023
Date Signed: 04/21/2023 12:37:26 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
04/19/2023 and conducted by Evaluator Laura Hall
COMPLAINT CONTROL NUMBER: 15-AS-20230419164602
FACILITY NAME:TELECARE HILLSIDE HOUSEFACILITY NUMBER:
079201018
ADMINISTRATOR:TIFFANY SPIECKERFACILITY TYPE:
737
ADDRESS:205 HILLSIDE ROADTELEPHONE:
(925) 433-0577
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY:4CENSUS: 4DATE:
04/21/2023
UNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Nelson Chimm, Lead TIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Staff cursed at a client while in care
INVESTIGATION FINDINGS:
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On 4/21/2023 at 11:10AM, Licensing Program Analysts (LPAs), L. Hall and L. Alexander arrived unannounced to conduct the 10-day initial visit and deliver complaint findings for the allegation above. LPA met with Nelson Chimm, Lead and explained the reason for the visit. LPA spoke with Administrator, Tiffany Speicker, via telephone and was given approval for Lead to sign documents.

During the course of the investigation LPA interviewed staff, RP, a witness , and collected the incident report dated 4/14/2023 and staff schedule. During interviews all stated the incident occurred. Staff 2 (S2) stated during interview the involved staff was from a registry, the facility terminated the staff assignment, and that staff will not return.

Continued on LIC9099C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2023
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 3
Control Number 15-AS-20230419164602
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: 04/21/2023
NARRATIVE
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Continued from LIC9099.

Based on LPA’s interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22 is being cited on the attached LIC 9099D.

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

DATE: 04/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20230419164602
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: 04/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/28/2023
Section Cited
CCR
80072(a)(1)
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(a) ... each client shall have personal rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff...
This requirment was not met as evidence by:
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Administrator immediately terminated S3's assignment on the day of the incident. S3 will not return. Deficiency cleared immediately following incident.
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Based on LPAs observation and record review the Licensee did not comply with the section cited above in make sure C1 was accorded dignity with staff, which poses a potential health and safety risk to person 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: 04/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3