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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803874
Report Date: 05/20/2022
Date Signed: 05/20/2022 01:54:08 PM

Document Has Been Signed on 05/20/2022 01:54 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:TELECARE ENGLISH HILLSFACILITY NUMBER:
486803874
ADMINISTRATOR:SPIECKER, TIFFANYFACILITY TYPE:
738
ADDRESS:7821 ENGLISH HILLS ROADTELEPHONE:
(707) 815-2511
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY: 4CENSUS: DATE:
05/20/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:TIME COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Felias, Regional Manager (RM) Nuti-Martinez, Courtney Singleton, North Bay Regional Center, Amir Cruz-Khalili, Department of Developmental Services, Administrator, Tiffany Spiecker and Administrator-in-Training (AIT), Adam Olives met to discuss a recent incident along with staffing concerns.

On March 18, 2022, the Regional Office (RO) received an incident report stating that on 3/18/2022, Client (C1) left the facility, withdrew consent to receive care services from facility, and checked into a hotel. C1 updated facility of their whereabouts and facility staff provided medication management and meals for C1 but no additional supervision.
RO learned from Department of Developmental Services that C1 required 1:1 staffing for a portion of their day. Additionally, C1’s physician report (LIC 602), page 2, Section III, Line Item 9, asks for a physician to determine if C1 can leave the facility unassisted based on the client's capacity for Self-Care. C1’s physician marked that C1 was not able to be in the community unsupervised. C1’s Behavior/IPP plan, did not address this detail and facility did not ensure that the two documents matched. The facility continued to provide services to C1 after they left the facility, failed to ensure C1 had appropriate supervision while in the community when C1 left the facility and self-checked into a nearby hotel.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 05/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/20/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 05/20/2022 01:54 PM - It Cannot Be Edited


Created By: Caitlynn Felias On 05/20/2022 at 01:34 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: TELECARE ENGLISH HILLS
FACILITY NUMBER: 486803874

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/20/2022
Section Cited
HSC
80078(a)

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80078(a) Responsibility for Providing Care and Supervision: The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement isn't met as evidenced by: Based on interview & records review facility staff didn't comply with
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Administrator will provide CCL with a plan as to how they will ensure a client's medical assessment and IPP Plan align with each other. In addition, Administrator agrees to conduct staff training regarding elopement and reporting.
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this section for C1 which required 1:1 staffing and could not be in the community unsupervised which poses an immediate health and safety risk to client in care.
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Facility to submit their plan to CCL by POC date 5/20/2022.
Facility to submit Proof of Staff Inservice Training w/participants signature, trainer signature, what was covered, & date of training to be submitted to CCL by 5/31/2022.

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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:Kimberley Mota
LICENSING EVALUATOR NAME:Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:
DATE: 05/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2022


LIC809 (FAS) - (06/04)
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