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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803874
Report Date: 01/21/2025
Date Signed: 01/21/2025 04:03:22 PM

Document Has Been Signed on 01/21/2025 04:03 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:TELECARE ENGLISH HILLSFACILITY NUMBER:
486803874
ADMINISTRATOR/
DIRECTOR:		CARVAJAL, ABBYFACILITY TYPE:
738
ADDRESS:7821 ENGLISH HILLS ROADTELEPHONE:
(707) 815-2511
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY: 4CENSUS: 4DATE:
01/21/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:20 PM
MET WITH:Abby Carvajal, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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At 12:20 PM on 1/21/2025, Licensing Program Analyst (LPA) Robert Frank and Licensing Program Manager (LPM) Victoria Bertozzi conducted an unannounced Annual Required – 1 yr. Inspection for this facility and was greeted by Heidi Noriesta and Administrator, Abby Carvajal. The facility currently provides care for four (4) clients, all of which were present at the time of visit. LPA continued with a tour of the facility with staff. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers were found to be last charged on 5/2024. Smoke and carbon monoxide detectors were interconnected found throughout the facility, tested and to be in working order. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were stored properly as per regulations on this day at the time of the visit. Water at faucets accessible to clients were measured between 105 degrees F and 120 degrees F which is within Title 22 Regulations. Facility conducts and records emergency disaster drills monthly. The last disaster drill was conducted on 1/4/2024.

Medications are located in a designated closet in the dining area and found to be secured. A spot medication count was conducted for two (2) of four (4) clients and found to be in order along with properly documented centrally stored medication and administration records. LPA conducted a review of five (5) staff files and found all staff files reviewed to have 1st Aid & CPR certification and annual training on file. In addition, LPA reviewed four (4) of four (4) client records and found all documents including Needs & Service Plan, North Bay Regional Center Individual Program Plans and Physician's Reports to be current. There is a sufficient supply of linens, hygiene product and paper products available for client use. Items that could pose danger to client if accessible were found to be secured. Clients were observed to have a positive relationship with staff and found participating in activities or meetings during the visit. Personal and incidental (P&I) monies were counted for two (2) clients. LPA & LPM observed that there was one (1) instance where a P&I log was not current. An LIC9102 Technical Advisory was issued and discussed with the Administrator.
Continued on 809-C
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Robert Frank
LICENSING EVALUATOR SIGNATURE: DATE: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/21/2025
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: TELECARE ENGLISH HILLS
FACILITY NUMBER: 486803874
VISIT DATE: 01/21/2025
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...Continued from 809.

Administrator, Abby Carvajal's Administrator Certification 7024293735 is current through 2/1/2025,
Administrator, Heidi Noriesta's Administrator Certification 7031544735 is current through 9/21/2025.

LPA requested the following documents be sent to CCL by COB 2/21/2025:

LIC 308 Designated Facility Responsibility
LIC 610D Emergency Disaster Plan

No deficiencies cited during today's visit. Exit interview conducted. Copy of report and LIC9102 (Technical Violations/Advisories) discussed and provided to Administrator. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Robert Frank
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2025
LIC809 (FAS) - (06/04)
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