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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701177
Report Date: 11/28/2022
Date Signed: 01/30/2023 03:01:56 PM

Document Has Been Signed on 01/30/2023 03:01 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:
11/28/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Athika KaroliaTIME COMPLETED:
01:00 PM
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On 11/28/22 at 12pm Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to complete a case management. LPA Jensen met with Administrator Athika Karolia and explained the purpose of today's visit.

LPA Jensen received 3 incident reports during the month of November for resident 1 (R1). LPA Jensen interviewed the Administrator to discuss the incidents and what action the facility is taking-See LIC 812. Based on the interview conducted the facility sought timely medical attention and has implemented actions necessary to mitigate the risk of future incidents.

No deficiencies are being cited today as a result of the 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: 11/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/28/2022
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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