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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392701177
Report Date: 07/17/2025
Date Signed: 07/17/2025 12:06:05 PM

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
05/07/2025 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20250507095410
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: 3DATE:
07/17/2025
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Amanda DuggiralaTIME COMPLETED:
12:20 PM
ALLEGATION(S):
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Staff mishandled a clients medications
INVESTIGATION FINDINGS:
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On 7-17-2025 at 11:15am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver findings for the allegation noted above. LPA met with direct care supervisor Amanda Duggirala and explained the purpose of the visit. During this investigation, LPA conducted interview with program director and reviewed incident reports dated 5-8-2025 and 6-29-2025. Additionally, needs and service plan for resident1 (R1) was reviewed. Based on interviews and record reviews, it was revealed that the following medication errors occurred:
On 5-8-2025, it was reported that on 5-8-2025 after a staff audit following a medication pass, two doses of medication Glycopyrrolate for resident2 (R2) were passed which resulted in R2 being double dosed. R2’s physician was notified of the medication error and gave additional orders to facility staff. It was further revealed through record review that this error occurred as a result of staff assisting in behavioral intervention while attempting to prepare medication.
{Cont .on 9099C}
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025
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-20250507095410
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: 07/17/2025
NARRATIVE
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On 6-29-2025, it was reported that on 6-27-2025 as staff member was conducting a medication audit staff noticed a discrepancy in the medication count for R2’s medication Carvedilol. The audit revealed that although marked in the log system as passed, R2’s PM dose of this medication had not been dispensed. Facility staff contacted R2’s physician and responsible party and continued to follow additional physician orders and instructions. The medication error was further confirmed by facility staff supervisor according to incident report.
Additionally, it was revealed that R1 attended a home visit outing with his responsible person on 5-6-2025. Medication documentation review revealed that medication was given to responsible party with signed acknowledgement of receipt. It was further revealed through interview that although R1 received his necessary medication for the outing, various labeling creating a discrepancy between AM and PM medication existed which resulted in the potential for a medication error.

Based on the investigation above, it is determined that medication was mishandled, therefore the preponderance of evidence standard is met, and this allegation is SUBSTANTIATED. Citation is issued and noted on LIC 9099D. A civil penalty in the amount of $250 issued in addition to citation due to a repeat violation of section 80075(b) within a 12-month period. An exit interview was conducted with direct care supervisor and a copy of this report was provide. Appeal rights and LIC 811 provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20250507095410
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: 07/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/18/2025
Section Cited
CCR
80075(b)
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80075(b) Health Related Services. 80075 Health Related Services. (b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement was not met as evidenced by:
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Licensee will ensure completed staff training on medication procedures including physician orders and seven rights of medication. Training date to be given to LPA by POC due date. Proof of completed training to be submitted to LPA no later than 7-31-2025.
Licensee will submit a protocol for preparing medication for clients in a safe, and effective manner. Plan to be submitted to LPA by POC due date.
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Based on interview and record review, facility staff did not appropriately assist with self-administration of medication for clients in care in that medications were not dispensed according to physician orders. This posed an immediate health and safety risk to residents 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: 07/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3