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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803874
Report Date: 01/17/2024
Date Signed: 01/17/2024 03:09:55 PM

Document Has Been Signed on 01/17/2024 03:09 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:OLIVES, ADAM J.FACILITY TYPE:
738
ADDRESS:7821 ENGLISH HILLS ROADTELEPHONE:
(707) 815-2511
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY: 4CENSUS: 3DATE:
01/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:16 AM
MET WITH:Heidi Noriesta, LVN & Abby Carvajal, Acting AdministratorTIME COMPLETED:
01:30 PM
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On 1/17/2024, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. Inspection for this facility and was greeted by Lead Staff, Sabrina Thomason. LVN, Heidi Noriesta and Acting Administrator, Abby Carvajal. The facility currently provides care for 3 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 7/26/2023. 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 at 111.5 degrees F which is within Title 22 Regulations. Facility conducts and records emergency disaster drills multiple times per month.

Medications are located in a designated closet in the dining area and found to be secured. A spot medication count was conducted for client and found to be in order along with properly documented centrally stored medication and administration records. LPA conducted a review for staff files and found all staff to have 1st Aid & CPR certification and annual training on file. In addition, LPA reviewed client record 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. Facility van was inspected and found to have appropriate emergency safety items including first aid kit and fire extinguisher. Clients were observed to have a positive relationship with staff and found participating in activities or meetings during the visit.

Continued onto LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HILLS
FACILITY NUMBER: 486803874
VISIT DATE: 01/17/2024
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During visit, internal corporation agency staff was reported to have confrontation with management about staffing tasks and responsibilities. Staff was immediately removed from the facility to prevent client reactions and ensure safety. Acting Administrator had reported the incident and internal investigation will be conducted.

In addition, LPA conducted a follow up on concerns during a previous visit from the Department of Developmental Services including, renovation plans for client restrooms, repairs to light switch covers, loose window frames and staff CPR certification. Upon inspection, LPA found all items to be completed or in the process of completion. One client restroom is currently under renovation with expected completion date within the same work week. Technical Advisories issued. LPA requested for facility to provide corrections the following items:

- 1st Aid & CPR and CPI Training Certificates for all staff ensuring items are on physical file
- 7 Day water temperature log for both client restrooms
- Window screens replaced in client restroom and client bedrooms
-LIC9098 Proof of Corrections confirming items are completed


Administrator, Abby Carvajal's Administrator Certification 6058338735 is current through 2/1/2025,
Administrator, Heidi Noriesta's Administrator Certification 6067317735 is current through 4/20/2025.

LPA requested the following documents be sent to CCL by COB 1/31/2024:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan (indicate 3rd evacuation site)
LIC 9020 Register of Facility Client’s/Resident’s
Liability Insurance
Proof of ownership/Control of Property

No deficiencies cited during today's visit.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 01/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2024
LIC809 (FAS) - (06/04)
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