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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701177
Report Date: 01/30/2024
Date Signed: 01/30/2024 03:56:28 PM

Document Has Been Signed on 01/30/2024 03:56 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: 2DATE:
01/30/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:26 PM
MET WITH:Danica MorrisonTIME COMPLETED:
02:00 PM
NARRATIVE
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On 1-30-24 at 1:26pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit for incidents regarding care and supervision and medication procedures. LPA met with Administrator Danica Morrison and explained the purpose of the visit. LPA conducted brief interview with Administrator.

Incident #1: Based on incident report dated 12-29-23, resident1 (R1) eloped from facility on foot at 6:15am. Facility staff followed R1 on foot and using the facility van. During this time, R1 ran away from staff towards nearby train tracks. Law enforcement was notified and offered assistance. R1 was found at approximately 7:20am and taken to local acute hospital for evaluation. Based on incident report and interview, it was determined that R1 was without staff supervision for approximately 30 minutes during this AWOL incident.

Incident #2: Based on incident report dated 1-26-24, facility staff was conducting an end of shift medication count for resident2 (R2). A medication, Guanfacine 1mg was indicated on the medication log sheet to have been passed on 1-26-24 during the morning shift, however, R2's bubble pack was observed by facility staff on evening shift to have shown this medication was not given, resulting in R2 missing the morning dosage.

As a result of today's case management, citations are issued under Title 22, Division 6. A civil penalty in the amount of $500 is issued in addition to the citation due to absence of supervision. An additional civil penalty in the amount of $250 is issued in addition to citation due to a repeat violation of Section 80075(b) within a 12-month period. An exit interview was conducted with Danica Morrison and a copy of this report was provided to Danica. Appeal rights provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/30/2024
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 01/30/2024 03:56 PM - It Cannot Be Edited


Created By: Michael Bilger On 01/30/2024 at 02:28 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: 01/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/31/2024
Section Cited
CCR
80078(a)

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Responsiblity 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 will submit a plan outlining proper AWOL procedures and prevention of abscense of supervision. Plan to be submitted to LPA by POC due date.
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Based on interview and record review, R1 eloped from facility resulting in an absence of supervision for approximately 30 minutes on 12-29-23. This posed an immediate health and safety risk to residents in care.
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Type A
01/30/2024
Section Cited
CCR80075(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 to ensure a plan outlining how staff will ensure residents receive all medications as prescribed. Plan to include but not be limited to: Regular audits. Plan to be submitted to LPA by POC due date.
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Based on interview and record review, R2 did not receive the prescribed morning medication of Guanfacine 1mg. This posed an immediate 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.
SUPERVISOR'S NAME:Liza King
LICENSING EVALUATOR NAME:Michael Bilger
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2024


LIC809 (FAS) - (06/04)
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