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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 04:34:57 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
07/22/2025 and conducted by Evaluator Michael Bilger
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20250722160650
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:
01:30 PM
MET WITH:Christina ManceTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Facility staff failed to use effective emergency interventions during a client's mental health event
INVESTIGATION FINDINGS:
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On 8-7-2025 at 1:30pm, 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 two staff members and reviewed facility file documentation including incident report dated 7-17-2025, individual program plan (IPP) for resident1 (R1), and needs and service plan for R1.
Allegation: Facility staff failed to use effective emergency interventions during a client's mental health event. LPA conducted interviews and record reviews as noted above. Based on interviews and record reviews it was revealed that on 7-17-2025 at approximately 6:03pm, R1 entered his room following a conversation with a family member. R1 closed the door and a few minutes later according to incident report, facility staff heard movement within R1’s room. When staff approached R1’s room, staff determined that R1 was upset and attempted to open R1’s room door. Facility staff were unable to open the door due to R1 sitting in front of the door while in his room. {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-20250722160650
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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Interviews and review of incident report revealed R1 began to throw items while asking to see his family member. Facility staff heard banging in the room and were unable to determine if R1 was banging his head or other body part. Facility staff then attempted to look through R1’s window from the outside, however, R1 had closed blinds. Facility staff attempted verbal de-escalation techniques but were unsuccessful. Interviews and incident report further revealed that staff were instructed to call R1’s responsible party for additional de-escalation techniques, but did not call 9-1-1 for intervention after learning of R1 barricading self in room along with concerns for physical safety. R1 opened door after speaking with responsible party at approximately 6:50pm. Facility staff assessed R1 for injuries and determined that R1’s forehead and back of head were red. R1 was transported to hospital by staff. No major injuries were noted as a result of this episode.
A review of R1’s IPP and needs and service plan revealed R1 has a history of self injurious behavior including head banging. Interviews conducted revealed facility staff stating that in hindsight, calling 9-1-1 would have been a better option.

As a result of this investigation, the preponderance of evidence standard is met, therefore, 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 the citation due to repeat violation of Section 80078(a) within a 12 month period. An exit interview was conducted with licensee designee and a copy of this report was provided via email with request to 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 3
Control Number 27-AS-20250722160650
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 to develop and submit an updated action plan regarding staff interventions on clients’ mental health crisis to include but not be limited to: Plans for de-escalation and behavior triggers. Plan to be submitted to LPA by POC date.
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 Based on interview and record review, Licensee did not ensure the use of necessary emergency services after R1 barricaded self in his room. This posed an immediate health and safety risk to resident in care; resident sustain injuries.
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Licensee will ensure completed staff training on proper emergency protocols during clients’ mental health crises. Training date to be submitted to LPA by POC due date. Proof of completed training to be submitted to LPA by 8-21-25.
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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)
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