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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392701177
Report Date: 08/07/2025
Date Signed: 08/07/2025 04:14:52 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
07/09/2025 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20250709135441
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:
01:00 PM
MET WITH:Christina ManceTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Client sustained multiple injuries while in care due to inappropriate care and supervision
INVESTIGATION FINDINGS:
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On 8-7-2025 at 1:00pm, 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 this investigation, LPA conducted interviews with three residents in care and reviewed facility file documentation including incident reports, individual behavior support plan (IBSP) pertaining to resident1 (R1), and facility program plan.

Allegation: Client sustained multiple injuries while in care due to inappropriate care and supervision. Based on interviews and record reviews noted above. It was revealed that on 6-28-2025, R1 was put into a supine hold for ten minutes after three unsuccessful attempts of a medium hold. Holds were used due to R1’s extreme behaviors including hitting and biting staff. R1 sustained injuries/bruising to areas of his hands and elbow. Interviews revealed that staff who performed the hold did not have arms secure properly and R1 was rubbing hands on cement causing the injuries. {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 3
Control Number 27-AS-20250709135441
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
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Additionally, interviews revealed that a staff member admitted to not being comfortable and trained well enough to perform the hold. Based on interviews, this staff member did participate in the assistance of the hold. Interviews further revealed that holds are not typically performed on the cement for safety reasons. A review of facility’s program design states that during a restraint, a trained staff member will be constantly assessing and monitoring the resident’s physical and psychological status to ensure health and safety including signs of injury, ensuring safety of the resident, and determining if the resident’s behavior poses an imminent risk of serious injury. R1’s IBSP revealed a history of behavior including but not limited to: Hitting and biting other.

As a result of this investigation, 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 is issued in addition to the citation due to repeat violation of Section 80078(a) within a 12-month period. An exit interview was conducted with {NAME} and a copy of this report was provided via email with request to return with signature. Appeal rights provided. 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 3
Control Number 27-AS-20250709135441
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)
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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:
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Licensee will ensure additional completed staff training on proper use of restraints. Training to include appropriate location and supervision during use of restraint. Training date to be submitted to LPA by POC due date. Proof of completed staff training to be sent to LPA by 8-21-2025.
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 Based on interview and record review, Licensee did not ensure proper care and supervision of R1 in that facility staff utilized an improper restraint procedure resulting in multiple injuries of R1. This posed an immediate health, safety, and resident rights 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: 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 3