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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201018
Report Date: 02/29/2024
Date Signed: 02/29/2024 01:02:15 PM

Unsubstantiated


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
11/13/2023 and conducted by Evaluator Laura Hall
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20231113100951
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:
02/29/2024
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Adam Olives, AdministratorTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Staff physically assaulted resident in care.
INVESTIGATION FINDINGS:
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On 2/29/2024, at 12:45pm, Licensing Program Analyst (LPA), L. Hall arrived unannounced to deliver complaint findings for the allegation above. LPA met with Administrator, Adam Olives, and explained the reason for the visit.

Allegation: Staff physically assaulted resident in care.

During the course of the investigation, LPA interviewed three (3) staff obtained and reviewed records. Reporting Party (RP) stated during initial complaint intake that Client 1 (C1) stated that a staff slapped, dragged, punched, and put their knee in C1’s stomach.

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

DATE: 02/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024
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 2
Control Number 15-AS-20231113100951
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: 02/29/2024
NARRATIVE
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Continued from LIC9099.

LPA reviewed an incident report dated and submitted on 9/24/2023, which was for the incident regarding the hold and breaking of the van windows. The incident report also indicated the involved parties were Staff 1 (S1) and Staff 5 (S5). The RP stated C1 stated the incident occurred on 11/11/2023.

C1 stated during an interview that while being placed in a hold he was kicked and stomped. C1 also stated the incident occurred when he broke the windows of the van but was not able to recall the exact date.

S1 stated during the interview that C1 was placed in a standing hold by S1 and S5 because of the behaviors C1 was experiencing. S1 stated C1 was placed in a hold so that could not injure himself or staff, but none of the staff assaulted C1. S1 also stated that she had not been involved in any other hold up to the interview date on November 15, 2023. Staff 3 (S3) and Staff 4 (S4) both recalled the incident of the hold occurring when C1 broke the windows out of the van, but stated they did not see any mistreatment towards C1. S3 stated she recalled the day being a Sunday. S3 and S4 also stated they could not be involved in the hold because neither were crisis prevention intervention (CPI) trained and were only allowed to observe. All three (3) staff stated that 9-1-1 had to be called and C1 was taken from the facility.

Based upon the information obtained during investigation. The above allegation is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview conducted and a copy of this report provided.

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

DATE: 02/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2