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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201018
Report Date: 07/05/2023
Date Signed: 07/05/2023 12:14:06 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
11/15/2022 and conducted by Evaluator Laura Hall
COMPLAINT CONTROL NUMBER: 15-AS-20221115153204
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:
07/05/2023
UNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Adam Olives, AdministratorTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Staff are mishandling a client while in restraints

Staff are mistreating a client while in care
INVESTIGATION FINDINGS:
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On 7/5/2023 at 10:55am, Licensing Program Analyst (LPA) L. Hall arrived unannounced to deliver complaint findings for the allegations above. LPA met with Adam Olives, Administrator, and explained the purpose of the visit.

During the course of the investigation, the Department conducted interviews with staff, Reporting Party (RP), Client 1 (C1), obtained and reviewed records, including required training. On the above allegation, Staff are mishandling a client while in restraints. Review of special incident report dated 10/23/2022 indicated C1 complained of pain and a bump from the restraint he was placed in on 10/20/2022. LPA reviewed the after-summary visit from the emergency department dated 10/23/2022, which indicated C1 sustained an injury to his sternum and the cause of

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

DATE: 07/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2023
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 4
Control Number 15-AS-20221115153204
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: 07/05/2023
NARRATIVE
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Continued from LIC9099.

the injury could have occurred from direct force to the sternum or a flexing (bending) injury. The Department interviewed fourteen (14) staff. Four (4) of the staff were present at the time of the incident. Staff 3 (S3) and Staff 4 (S4) were involved in the restraint placed on C1 twice in the same day. During interview with Staff 5 (S5) it was stated that on 10/20/2022, S5 observed C1’s wrist being bent all the way down (demonstrated) and S3 took C1’s head and shoved it down between C1’s legs (demonstrated). Staff 6 (S6) was also present during the incident on 10/20/2022 and stated C1 was upset, staff started to escort C1 to his room when C1 tried to inflict self injurious pain. S6 further stated later the same C1 tried to grab S5’s ponytail, so staff tried to escort C1 back to his room. S6 stated while staff was escorting C1 he went back to get a sweater and when he returned to the hallway S3 and S4 had C2 had to restrain C1 a second time on 10/20/2022. S6 recalled during the interview that a few days after the incident C1 complained about chest pain and was taken to the hospital. LPA interviewed C1. During the interview with C1 it was stated that S3 and S4 beat him up and that it happens all the time. Based on the investigation the above allegations are substantiated.
On the allegation Staff are mistreating a client while in care. LPA reviewed the detailed supportive information received from the RP on 11/15/2022. The RP stated an email was received from S5 that stated there were two staff members and S3 and S4 were named, that were mistreating and handling the clients roughly. S5 stated there was a previous incident (unknown date) it was observed where S3 and Staff 4 (S4) had C1’s arms pulled back, put pressure on C1’s back, and put C1’s head between his legs. S5 stated C1 was grasping for air. On 1/12/2023, LPA received and reviewed the investigation that was completed in-house by the facility, which stated based on witnesses statements the facility determined that staff S3

Continued on LIC9099C.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 07/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 15-AS-20221115153204
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: 07/05/2023
NARRATIVE
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Continued from LIC9099C.

and S4 used inappropriate restraint techniques that may have caused physical injury and/or emotional distress.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. 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.

A $500.00 immediate civil penalty is assessed on this day. Licensee was informed that an additional civil penalty is still being determined based on Health & Safety Code 1548.

A Non-Compliance Conference (NCC) will be scheduled for a later date.

Exit interview conducted. Appeal Rights and a copy of this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 07/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 15-AS-20221115153204
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: 07/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/06/2023
Section Cited
CCR
80072(a)(3)
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80072 (a) ...each client shall have personal rights which include...
(3) To be free from corporal or unusual punishment, infliction of pain... threat, mental abuse...
This requirement was not met as evidence by:
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Licensee immediately corrected by terminating S4 on 12/23/2022 after in-house investigation completed and S4 resigned in lieu of termination. Licensee re-trained staff on Mandated reporting, abuse prevention, Client Rights and Client Dignity in November and December 2022. LPA obtained in-service training sign-in sheet during visit. Deficiency cleared.
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Based on LPA's interviews and record review the Licensee did not comply with the section cited above in protect client's personal rights, which posed a health and safety risk to person in care.
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Type A
07/06/2023
Section Cited
CCR
80072(a)(1)
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80072 Personal Rights

(a) Except for children’s residential facilities, 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 and other persons.
This requirement was not met as evidence by:
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See above.
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Based on LPA's interviews and record review the Licensee did not comply with the section cited above in protect client's personal rights, which posed a 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: 07/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4