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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803874
Report Date: 05/09/2024
Date Signed: 05/09/2024 05:04:23 PM

Document Has Been Signed on 05/09/2024 05:04 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/
DIRECTOR:		TIFFANY SPIECKERFACILITY TYPE:
738
ADDRESS:7821 ENGLISH HILLS ROADTELEPHONE:
(707) 815-2511
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY: 4CENSUS: 3DATE:
05/09/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:45 PM
MET WITH:Heidi Noriesta, LVN ManagerTIME VISIT/
INSPECTION COMPLETED:
05:15 PM
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On 5/9/2024, Licensing Program Analyst, Tobola arrived unannounced and was greeted by LVN Manager, Heidi Noriesta. The purpose of the visit is to follow up on several incident reports and facility initiated report of suspected abuse involving client (C1). Incident reports indicate reoccurrences of escalated actions of client C1 involving C1 causing property damage, self injurious behaviors, elopement and potentially putting other clients' personal rights at risk.

Facility implemented protocol to ensure staff provide additional supervision for C2 protecting their personal rights. Protocol includes redirecting C2 to their bedroom or closing C2's bedroom door with staff preventing C1 from engaging with C2 during incidents. LPA was informed that C2 is currently in the process of transitioning to a new facility with potential transfer dates.

LPA informed that continuous room checks and a 24/7 line of sight have been implemented for supervising C1. Medication updates and additional electronic devices have been implemented for C1 to help with keeping C1 at baseline potentially alleviate the amount of incidents. LPA and LVN Manager discussed and incident on 4/8/2024 in which C1 was supervised by staff (S1) resulting in C1 leaving line of sight. C1 had not been located for approximately one and a half hours. The property has a large plot of land towards the facility road entrance where C1 had been located. However, facility failed to ensure appropriate supervision. Facility immediately took administrative action to correct the incident. Management will be holding a meeting to further discuss C1's placement and health & safety admitted to the facility.

Lastly, LPA and LVN Manager discussed previous alleged incident involving staff (S2) and gathered facility and client documents.

Deficiency 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: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2024
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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Document Has Been Signed on 05/09/2024 05:04 PM - It Cannot Be Edited


Created By: Dominic Tobola On 05/09/2024 at 04:07 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: 05/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/10/2024
Section Cited
CCR
80065(a)

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(a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs. This was not met as evidence by:**
Based upon interview with staff and facility
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Licensee has taken immediate corrective actions and terminated staff S1. Additional supervision and update to level of care has been implemented for C1. Deficiency cleared at time of visit.
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incident report. It was found that on 4/8/2024, staff (S1) had lost line of sight for client (C1), resulting in C1 eloping. This is an immediate health and safety risk to client in care.
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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:Dominic Tobola
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2024


LIC809 (FAS) - (06/04)
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