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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201018
Report Date: 04/06/2023
Date Signed: 04/06/2023 04:05:46 PM

Document Has Been Signed on 04/06/2023 04:05 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:
04/06/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Nicolas, Dedicatoria, LeadTIME COMPLETED:
04:15 PM
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On 4/6/2023 at 3:15PM, Licensing Program Analyst (LPA), L. Hall arrived unannounced to conduct a case management visit regarding an incident report. LPA met with Nicolas Dedicatoria, Lead and explained the reason for the visit. Regional Manager, Tiffany Spiecker arrived 3:35PM.

The Department received an incident report dated 3/27/2023. During review of the incident report LPA L. Hall observed S3 was not associated to the facility but was providing care to the clients.

During interview with S2 it was stated that S4 legal last name is different than what was written on the incident report. LPA checked guardian and observed S3 name listed.

No deficiency cited during visit.

Exit interview conduct and a copy of this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 04/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/06/2023
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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