<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392701177
Report Date: 08/07/2025
Date Signed: 08/07/2025 03:38:36 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
06/24/2025 and conducted by Evaluator Michael Bilger
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20250624113728
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:
08/07/2025
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Christina ManceTIME COMPLETED:
12:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Client sustained multiple serious injuries due to lack of care from staff
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 8-7-2025 at 11:30am, Licensing Program Analyst (LPA) and Licensing Program Manager (LPM) Liza King met with licensee designees Christina Mance and Amanda Duggirila via Teams meeting to deliver findings for the allegation noted above. During the course of this investigation, LPA conducted interviews with two staff members and reviewed facility file documentation including individual program plan for resident1 (R1), needs and services plan for R1, and individual behavior support plan (IBSP) for R1. Additionally, LPA reviewed communication documentation between staff and R1’s responsible party, as well as incident report dated 6-14-25.
Allegation: Client sustain multiple serious injuries due to lack of care from staff. Based on interviews and record reviews, it was revealed that on 6-12-25, facility staff was transporting R1 home from an outing when he became upset. R1 punched the driver and threw his phone at the driver, causing staff to pull over to the side of the road. Staff exited vehicle and kept safe distance between themselves and R1. R1 hit head twice on the vehicle window and began hitting himself on the head with closed fists. R1 then exited the car and attempted to hit staff as well as throw rocks at them. {Cont. on 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 08/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2025
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 4
Control Number 27-AS-20250624113728
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: 08/07/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Additional staff accompanying another resident pulled over to offer assistance and de-escalation techniques, witnessing the event. R1 then began to lay on the street and bang his head on the asphalt until bleeding occurred. Report described "repeated blows to the head" and then called an ambulance for assistance. Interviews and record reviews further revealed R1’s history of head banging and other self injurious behaviors. On the day of this event, it was revealed that although staff attempted de-escalation techniques on R1, staff did not utilize protective equipment and other materials used to help prevent injuries. A review of individual behavior support plan revealed protective equipment may be used in the event of self injurious behavior. Additionally, on 6-28-25, it was a revealed through email communication that R1 sustained a rash on his lower extremities. Email communication between R1 and facility staff revealed that staff were not ensuring the regular and adequate placement of a special boot to be placed on R1’s foot, which led to the rash occurrence.

As a result of the above investigation, the preponderance of standard is met, and this allegation is SUBSTANTIATED. Citation is issued under Title 22, Division 6 and noted on LIC 9099D. A civil penalty in the amount of $250 is issued in addition to citation due to repeat violation of Section 80078(a) within a 12-month period. An exit interview was conducted with licensee designees and a copy of this report was provided via email with request for return with signature. Appeal rights and LIC 811 provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 08/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20250624113728
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: 08/07/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/08/2025
Section Cited
CCR
80078(a)
1
2
3
4
5
6
7
80078 Responsibility for Providing Care and Supervision. (a) The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee to ensure completed staff training on various care and supervision techniques including but not limited to: Emergency interventions necessary to avoid injuries, and safe transportation procedures. Training date to be submitted to LPA by POC due date. Proof of completed training to be sent to LPA by 8-21-25.
8
9
10
11
12
13
14
 Based on interviews and record reviews, facility staff did not provide adequate care and supervision for R1 resulting in multiple injuries. This posed an immediate health and safety risk to resident in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 08/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
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
06/24/2025 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20250624113728

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:
08/07/2025
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Christina ManceTIME COMPLETED:
12:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not keep client and client's authorized person informed about client's care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 8-7-2025 at 11:30am, Licensing Program Analyst (LPA) and Licensing Program Manager (LPM) Liza King met with licensee designees Christinia Mance and Amanda Duggirila via Teams meeting to deliver findings for the allegation noted above. During the course of this investigation, LPA conducted interviews with staff3 (S3) and reviewed communication documentation between staff and R1’s responsible party.
Allegation: Staff did not keep client and client’s authorized person informed about client’s care. Based on interview and documentation review, it was revealed that facility staff have communicated with necessary parties regarding resident1 (R1) including follow up emails, scheduled meetings, and text messages regarding additional plans of care.
As a result, there is not a preponderance of evidence to concluded staff have not informed parties about client’s care in an appropriate manner, therefore, this allegation is UNSUBSTATIATED.The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with licensee designees and a copy of this report was provided via email with a request for return with signature. Appeal rights provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 08/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4