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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201018
Report Date: 07/17/2023
Date Signed: 07/17/2023 11:32:24 AM

Document Has Been Signed on 07/17/2023 11:32 AM - 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:TIFFANY SPIECKERFACILITY TYPE:
737
ADDRESS:205 HILLSIDE ROADTELEPHONE:
(925) 433-0577
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 4CENSUS: 4DATE:
07/17/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Dejah Jordan, Direct Support ProfessionalTIME COMPLETED:
11:45 AM
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On 7/17/2023 at 11:15am, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct a Case Management visit. LPA met with Dejah Jordan, Direct Support Professional (DSP). LPA spoke with Administrator, Tiffany Spiecker, via telephone and was given approval for DSP to sign documents.

LPA visited the facility to deliver two (2) Immediate Exclusion letters. LPA verified that Staff 1 (S1) and Staff 2 (S2) was no longer present or working at the facility and delivered the letters to the Dejah Jordan, Direct Support Professional.

No deficiencies cited during the visit.

Exit interview conducted. Copies of the exclusion letters and this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 07/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/17/2023
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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