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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701177
Report Date: 11/22/2022
Date Signed: 11/28/2022 02:36:22 PM

Document Has Been Signed on 11/28/2022 02:36 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:TELECARE WHITE LANEFACILITY NUMBER:
392701177
ADMINISTRATOR:KAROLIA, ATHIKA H.FACILITY TYPE:
737
ADDRESS:1775 WHITE LANETELEPHONE:
(209) 921-6872
CITY:STOCKTONSTATE: CAZIP CODE:
95215
CAPACITY: 4CENSUS: 2DATE:
11/22/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Athika KaroliaTIME COMPLETED:
03:00 PM
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On 11/28/22 at 1:00 pm Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a post licensing inspection. LPA Jensen met with Administrator Athika Karolia and explained the purpose of today's visit.

LPA Jensen toured the inside and the outside of the facility. The grounds were observed to be maintained and all paths were free of obstruction. The interior was observed to be free of odor and sanitary. There was adequate furnishings for the comfort of the residents. The facility was adequately lit. All window screens were determined to be in good repair. LPA Jensen observed a 2 day supply of perishable food and 7 day supply of non-perishable food. All food products were labeled with date opened and date of expiration. No expired food was observed. The water temperature in the bathroom was measured at 116.4 degrees which falls within the required regulatory range. The temperature in the facility was measured at 68 degrees which falls within the required regulatory range. All sharp objects and toxins were observed to be locked and inaccessible to residents in care. Medication was observed to be locked and inaccessible to residents care. Narcotics were observed to be locked separately from other medications. LPA Jensen reviewed the actual supply of narcotics and compared it against the Medication Administration Record and determined the records to be accurate. During the course of the visit LPA Jensen interacted with Resident 1 (R1) and reviewed the file for R1.

LPA Jensen requested a letter from the Licensee requesting an update to the contact phone number and a current copy of the liability insurance, surety bond and LIC 500 to be emailed to maja.jensen@dss.ca.gov by 12/5/22.

No deficiencies were cited as a result of this visit. An exit interview was conducted and a copy of this report was given to the Administrator.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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