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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803874
Report Date: 04/07/2022
Date Signed: 04/07/2022 12:32:45 PM

Document Has Been Signed on 04/07/2022 12:32 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: 3DATE:
04/07/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:33 AM
MET WITH:Administrator, Tiffany Speicker TIME COMPLETED:
12:44 PM
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At approximately 11:15AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management visit and met with Administrator, Tiffany Spiecker and Administrator-in-Training (AIT), Adam Olives.

LPA Felias requested additional documents from facility regarding an incident involving Client 1 (C1), which stated that on 3/18/2022, the client left the facility and withdrew consent to receive services. LPA to review documents in order to investigate further.

LPA, Administrator, and Administrator-in-Training (AIT) discussed Change of Administrator status and transition. Per conversation with Administrator and AIT, facility received provisional approval from the Department of Developmental Services (DDS) recognizing Adam as the Administrator. LPA clarified that an active certificate is needed in order for transition to occur as CCL covers Title 22 regulations and therefore has different requirements than DDS which covers Title 17. Therefore, Tiffany will need to stay as Administrator until Adam receives an active certificate and submits the proper documents for Change of Administrator to occur.

No Deficiencies cited during visit.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/07/2022
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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