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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803874
Report Date: 05/16/2023
Date Signed: 05/16/2023 12:33:08 PM

Document Has Been Signed on 05/16/2023 12:33 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:
05/16/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Interim Administrator Trainee, Iris Ruther
Regional Program Director, Tiffany Spiecker		TIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA), Farhaan Sarangi and Behavioral Specialist II (BSII), Amir Cruz-Khalil from the State of California-Department of Developmental Services arrived unannounced at Telecare English Hills for the purpose of conducting a Case Management-Incident Inspection. LPA was greeted at the door by Interim Administrator Trainee, Iris Ruther, and was granted access into the facility. Regional Program Director, Tiffany Spiecker arrived 45 minutes later.

During the course of the Case Management-Incident inspection, LPA and BSII toured the facility including the room of Former Client #1 and made observations. LPA and BSII requested the following documents to be reviewed at the facility:

-Special Incident Reports (SIRS)
-Debrief documents
-Medication Assessment Record (MAR) for Former Client #1
-Behavioral Plan for Former Client #1

No deficiencies were observed or cited during today's Case Management-Incident inspection. Exit interview was conducted and a copy of this report was given to the Regional Program Director.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/16/2023
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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