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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803874
Report Date: 12/18/2024
Date Signed: 12/18/2024 11:29:00 AM

Document Has Been Signed on 12/18/2024 11:29 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:TELECARE ENGLISH HILLSFACILITY NUMBER:
486803874
ADMINISTRATOR/
DIRECTOR:		NORIETSA,HEIDIFACILITY TYPE:
738
ADDRESS:7821 ENGLISH HILLS ROADTELEPHONE:
(707) 815-2511
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY: 4CENSUS: 4DATE:
12/18/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Heidi Norietsa, AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Nakagawa arrived unannounced to follow up on a self-reported incident involving a client C1. LPA was greeted by Care Team including Administrator Heidi Norietsa.

The facility self reported on 12/05/2024 that C1 was exhibiting behaviors, including possible self-harm. Administrator who is a nurse was able to assess C1 and found no evidence of self-harm, but rather attention-seeking. Administrator stated that C1's current Individual Behavior Support Plan (IBSP) was being met, however C1's care team meets weekly and will discuss the incident. C1 will continue with the IBSP which includes constant line of sight supervision, with additional supports given as needed.

LPA reviewed records and made observations.LPA toured portions of the facility and found the environment, including C1's room to be free from hazards. Sharps and electrical cords are locked and stored in staff office, along with cleaning supplies.

No deficiencies found at time of inspection.
No citations issued.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 12/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/18/2024
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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