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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201018
Report Date: 03/03/2023
Date Signed: 03/03/2023 01:39:26 PM

Document Has Been Signed on 03/03/2023 01:39 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:
03/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Sonya Sowell, LeadTIME COMPLETED:
01:45 PM
NARRATIVE
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On 3/3/2023 at 09:40AM, Licensing Program Analyst (LPA) L. Hall conducted an unannounced annual required inspection. LPA met with Sonya Sowell, Lead, and explained the purpose of the visit. LPA toured the facility with Lead, Sonya Sowell. The administrator currently holds a certificate (#6048326735) that expires on 3/12/2024. Co-Administrator, Nicolas Dedicatoria, arrived at 11:50AM. The facility’s fire clearance was approved for four (4) non-ambulatory clients.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of four (4) total bedrooms which are occupied by the clients. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 72 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 114.5 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. Hand washing poster, paper towel, and soap observed at all hand washing stations. The supply of extra hygiene was available for residents. PPE and paper goods are sufficient. There is a minimum of 7-day non-perishables and 2-day perishables foods.

Continued on LIC9099C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 03/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/03/2023
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: 03/03/2023
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Continued from LIC9099.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 1/14/2022. Emergency Disaster Plan was last posted on 09/07/2022. First aid kit was observed to be complete. Fire drill was last conducted on 2/21/2023.

Four (4) of six (6) Staff records were reviewed, and all staff have criminal record clearance. All four (4) clients records reviewed and were incomplete and P & I.

The following forms to be updated and submitted to CCLD by 03/102023:

LIC 500 Personnel Report
LIC 400 Affidavit Regarding Client/Resident Cash Resources
LIC 402 Surety Bond

LPA observed the following deficiencies:
  • At 11:45AM, LPA observed clients records were not current or complete.
  • At 12:30PM, LPA observed staff records were not complete.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in Civil Penalties.

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: 03/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023
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Document Has Been Signed on 03/03/2023 01:39 PM - It Cannot Be Edited


Created By: Laura Hall On 03/03/2023 at 01:08 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: 03/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
89970(a)
Client Records
(a) The licensee shall ensure the client records include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in having client records complete and current which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/10/2023
Plan of Correction
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Co-Administrator agreed to have all records completed and current. Co-Administrator will submit a self-certification of completion to CCLD by POC date.
Type B
Section Cited
CCR
80066(a)
80066 Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on(observation and record review, the licensee did not comply with the section cited above in having staff file complete which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/10/2023
Plan of Correction
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Co-Administrator agreed to complete staff files and submit self-certification that the files are completed to CCLD by POC date.
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: 03/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/03/2023


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