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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701177
Report Date: 12/19/2023
Date Signed: 12/19/2023 03:13:25 PM

Document Has Been Signed on 12/19/2023 03:13 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:MONTEL JENNINGSFACILITY TYPE:
737
ADDRESS:1775 WHITE LANETELEPHONE:
(510) 621-9064
CITY:STOCKTONSTATE: CAZIP CODE:
95215
CAPACITY: 4CENSUS: 3DATE:
12/19/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:28 PM
MET WITH:Amanda DuggiralaTIME COMPLETED:
03:30 PM
NARRATIVE
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On 12-19-23 at 1:28pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding care plan updates and medication management. LPA met with lead direct support staff Amanda Duggirala and explained the purpose of the visit. LPA conducted brief interview with direct support staff and reviewed facility file documentation including updated care plan and transition plan for resident1 (R1), medication list for R1, and current staffing plan. LPA also conducted a facility observation. LPA observed 6 staff currently on duty for 2 clients in care. Facility has 3:1 staffing ratio for R1. Staffing plan reviewed indicates 7 staff on duty for AM and PM with 4 staff on duty for night shift while all clients are in care. Medication list for R1 has been updated to reflect new medication for R1. Medication list indicates a total of 6 new medication and dosage changes. No recent incidents regarding attempts to elope or increased agitation noted since R1's return to facility on 12-13-23. Facility staff reports R1 has been at baseline since return.

LPA also reviewed incident report dated 12-11-23. Incident report states that on 12-10-23, facility staff conducted a medication count and discovered R2's medication Divalproex was off by 1 count. Upon further discovery by facility staff it was determined that R2 received 1 dose of Divalproex instead of the prescribed 2, thus resulting in a medication error.

As a result of today's case management, citation is issued under Title 22, Division 6 and noted on LIC 809D. An exit interview was conducted with Amanda Duggirala and a copy of this report was provided to Amanda. Appeal rights provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 12/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2023
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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Document Has Been Signed on 12/19/2023 03:13 PM - It Cannot Be Edited


Created By: Michael Bilger On 12/19/2023 at 02:11 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: 12/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/20/2023
Section Cited
CCR
80075(b)

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Health Related Services. (b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement was not met as evidenced by:
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Licensee will ensure completed staff training on assistance with providing medication. Training to include but not be limited to: Medication physician's orders, six rights of medication. Training date to be submitted to LPA by POC due date. Proof of completed staff training to be submitted to LPA
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Based on record review and interview, R2 received 1 dose of Divalproex medication instead of the prescribed 2 doses. This posed an immediate health and safety risk to residents in care.
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no later than 2 weeks from date of citation issuance.

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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.
SUPERVISOR'S NAME:Liza King
LICENSING EVALUATOR NAME:Michael Bilger
LICENSING EVALUATOR SIGNATURE:
DATE: 12/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2023


LIC809 (FAS) - (06/04)
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