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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701177
Report Date: 10/23/2025
Date Signed: 10/23/2025 03:43:12 PM

Document Has Been Signed on 10/23/2025 03:43 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:TELECARE WHITE LANEFACILITY NUMBER:
392701177
ADMINISTRATOR/
DIRECTOR:		DANICA MORRISONFACILITY TYPE:
737
ADDRESS:1775 WHITE LANETELEPHONE:
(510) 621-9064
CITY:STOCKTONSTATE: CAZIP CODE:
95215
CAPACITY: 4CENSUS: 2DATE:
10/23/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:58 PM
MET WITH:Danica MorrisonTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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On 10-23-2025 at 2:58pm Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding a previous report generated from an outside compliance agency. LPA met with Administrator Danica Morrison and explained the purpose of the visit. During this visit, LPA met with Administrator and reviewed agency inspection report dated 5-21-2025. Report was given to Licensee on 10-17-2025. Based on review, it was determined that on 5-21-25, various areas of care and supervision, documentation, and physical plant were out of compliance. Such areas included but not limited to: (1) A junction box for the front gate was observed on the ground with exposed wiring, the gravel covering the driveway for the PVC piping (for remote gate) was unlevel and exposed the PVC piping along the entryway to the home in two areas creating a trip and fall hazard, the pleated blinds covering the living room window were torn in several locations, a large area of peeling and chipping paint (approximately 24 inches in length) existed along the right side of the door frame around the door that exits to the backyard, the left arm of the turquoise chair in the living room had a large tear (approximately six inches long by one inch wide), and the Medication Administration Record (MAR) was reviewed, and a medication error was identified.

The MAR demonstrated that on 05/10/25, medications were passed to resident1 (R1). However, the MAR also identified that three medications were not provided to the R1 on the morning of 05/10/25. Additional findings included but not limited to: Monthly regional center meeting not scheduled monthly, regional center meetings identified various individual behavior support plans containing inconsistencies with graphs, charts, and reporting data, various fidelity checks not completed for January – February 2025, inaccurate information was identified on multiple incident reports, {Cont. on 809C}

NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Michael Bilger
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/23/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/23/2025
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an instance of an improper hold regarding R2 occurred on 12-10-2024 but not reported to all appropriate agencies, facility did not maintain documentation necessary to verify a certified administrator of record on duty after current Administrator certification expired on 4-17-2025, and a staffing schedule reviewed on 4-3-2025 demonstrated that facility did not have a lead staff member on duty for the 11pm-7am night shift.

As a result of this case management, citation is issued under Title 22, division 6. A civil penalty was issued in addition to citation due to repeat violation of Section 80064(a)(3) within a 12-month period. An exit interview was conducted with Administrator and a copy of this report was provided. Appeal rights provided.

NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Michael Bilger
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/23/2025 03:43 PM - It Cannot Be Edited


Created By: Michael Bilger On 10/23/2025 at 03:04 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: TELECARE WHITE LANE
FACILITY NUMBER: 392701177

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/23/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/06/2025
Section Cited
CCR
80064(a)(3)

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80064 Adminsitrator-Qualifications and Duties. (a) The administrator shall have the following qualifications: (3) Knowledge of and ability to comply with applicable law and regulation. This requirement was not met as evidenced by:
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Licensee or designee will review compliance report dated 10-17-2025 and develop plan to address and correct listed deficiencies. Plan and identified corrections to be submitted to LPA by POC due date.
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Based on record review, various areas of deficiencies were identified by an outside compliance agency on 5-21-2025 which violated applicable law and regulations including but not limited to: Medications, physical plant, and care and supervision. This posed a potential health and safety risk to residents 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.
Liza King
NAME OF LICENSING PROGRAM MANAGER:
Michael Bilger
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2025


LIC809 (FAS) - (06/04)
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