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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701177
Report Date: 08/26/2022
Date Signed: 08/26/2022 03:41:19 PM

Document Has Been Signed on 08/26/2022 03:41 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:TELECARE WHITE LANEFACILITY NUMBER:
392701177
ADMINISTRATOR:KAROLIA, ATHIKAFACILITY TYPE:
737
ADDRESS:1775 WHITE LANETELEPHONE:
(209) 921-6872
CITY:STOCKTONSTATE: CAZIP CODE:
95215
CAPACITY: 4CENSUS: 0DATE:
08/26/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Athika Karolia/Sharene KacyraTIME COMPLETED:
04:00 PM
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On 8/26/22 Licensing Program Analyst (LPA) Maja Jensen arrived at facility announced to conduct a pre-licensing visit. LPA Maja Jensen met with Administrator Athika Karolia and Administrator Sharene Kacyra and explained the purpose of today's visit.

The facility is a single story structure with a wrought iron gate in the front yard and a redwood fence in the backyard. The grounds are landscaped and free of obstruction. The facility was observed to be sanitary and free of odor. The facility is licensed for 4 and can accept up to three clients that are non-ambulatory. Facility sketches are posted throughout and are in compliance. The facility was equipped with adequate lighting. LPA Jensen toured the facility including but not limited to dining room, kitchen, living room, bedrooms, office, laundry room, garage and grounds. There is a barn on the premises that is not part of the facility and will remain locked.

The kitchen was observed to be fully equipped and all drawers and cabinets are labeled. Knives and sharp objects are locked and inaccessible to residents. Toxins and cleaning supplies are locked and inaccessible to residents. Snacks are easily accessible to residents. 4 of 4 bedrooms were observed to be adequately furnished. There was an ample supply of linens available. The bathroom water temperature was measured at 108 degrees. The bath/shower areas are built with non-slip flooring material. The kitchen water temperature was measured at 111 degrees. The water bacteriological analysis was completed on 7/25/22 and was reviewed and is in compliance. The facility retains 4 first aid kits that are complete with manual, scissors, tweezers, thermometer and various wound dressings. There are two emergency supply kits with enough supplies for 5 people each. The fire alarm is combined with the carbon monoxide detector and was determined to be in good working order.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 08/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2022
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: TELECARE WHITE LANE
FACILITY NUMBER: 392701177
VISIT DATE: 08/26/2022
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The backyard has ample seating and two shaded areas for the comfort of the clients. All walkways and passages are free of obstruction.

A mock resident file and the admission agreement was reviewed and found to be in compliance. The administrator holds a current certificate good through 12/5/23. The medication will be stored in a locked garage in a double locked cabinet. There is also a medication refrigerator in the locked garage. The facility has a generator for emergency use. The LIC 610D is posted and in compliance.

The facility was found to be in substantial compliance with the California Code of Regulations, Title 22, Division 6 and in substantial compliance with the Health and Safety Code. The facility has passed the pre-licensing inspection.

A component III presentation and an exit interview was conducted. A copy of this report was given to Administrator Athika Karolia.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022
LIC809 (FAS) - (06/04)
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