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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392701177
Report Date: 05/22/2024
Date Signed: 05/22/2024 11:16:53 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/14/2024 and conducted by Evaluator Michael Bilger
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240314134838
FACILITY NAME:TELECARE WHITE LANEFACILITY NUMBER:
392701177
ADMINISTRATOR:DANICA MORRISONFACILITY TYPE:
737
ADDRESS:1775 WHITE LANETELEPHONE:
(510) 621-9064
CITY:STOCKTONSTATE: CAZIP CODE:
95215
CAPACITY:4CENSUS: 2DATE:
05/22/2024
UNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Danica MorrisonTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Staff mistreating resident physically and mentally
INVESTIGATION FINDINGS:
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On 5-22-24 at 10:25am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver and discuss findings for the allegation noted above. LPA met with Administrator Danica Morrison and explained the purpose of the visit. During this investigation, LPA conducted interviews with eight staff members and 2 residents in care. LPA also reviewed facility file documentation including facility internal investigation report, incident report dated 3-13-24, staff file review for staff2 (S2), care staff notes, behavior notes for residient1 (R1), physician’s report for R1, and regional center documentation.

Based on interviews and record reviews, it was determined that on the approximate dates of 3-10-2024 and 3-11-2024, S2 engaged in a conduct described in facility’s internal investigation as physically and emotionally mistreating R1.

{Cont. on 9099C}
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 27-AS-20240314134838
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: TELECARE WHITE LANE
FACILITY NUMBER: 392701177
VISIT DATE: 05/22/2024
NARRATIVE
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Based on additional record review, these specific actions included “trust falling” and placing S2’s body weight on R1, jumping on R1’s back, pushing R1’s back to prompt R1 to move faster, and use of intimidation through other non-physical means.

As a result, it is determined that the preponderance of evidence standard is met, and this allegation is SUBSTANTIATED. An exit interview was conducted with Danica Morrison and a copy of this report was provided to Danica. Appeal rights provided. LIC 811 provided for reference.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20240314134838
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: TELECARE WHITE LANE
FACILITY NUMBER: 392701177
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/23/2024
Section Cited
CCR
80072(a)(3)
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Personal Rights. (a) …each client shall have personal rights which include, but are not limited to, the following: (3) To be free from...humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature…This requirement was not met as evidenced by:
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Licensee will ensure completed updated abuse training with topics to include physical and non-physical staff interaction with residents which may constitute abuse. Training to focus on abuse prevention.
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Based on interview and record review, S2 engaged in physical and emotional mistreatment of R1 including acts of mental and physical intimidation. This posed an immediate health and safety risk to resident 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.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3