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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701177
Report Date: 03/12/2024
Date Signed: 03/12/2024 03:50:20 PM

Document Has Been Signed on 03/12/2024 03:50 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:DANICA MORRISONFACILITY TYPE:
737
ADDRESS:1775 WHITE LANETELEPHONE:
(510) 621-9064
CITY:STOCKTONSTATE: CAZIP CODE:
95215
CAPACITY: 4CENSUS: 2DATE:
03/12/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Danica Morrison (via telephone)TIME COMPLETED:
04:05 PM
NARRATIVE
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On 3-12-24 at 12:35pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit. The purpose of today's case management is to address a facility reported medication error and LPA follow up on a previously reported incident involving resident1 (R1's) absence without leave (AWOL) and Fentanyl found in R1's system. LPA met with Administrator Danica Morrison via phone and explained the purpose of the visit. Administrator gave permission for lead caregiver (S8) to sign in her absence.

Incident #1: LPA reviewed incident report dated 2-15-24 which states on 02/15/2024 at approximately 5:00am during a medication count, it was discovered by night staff that R1's Divalproex was off by 1 count. S8 concluded that she had given 1 dose of his evening Divalproex instead of 2, resulting in a medication error. Staff contacted R1's physician at 8:50am on 2-15-24 to inform him of the error and to get instruction on how to proceed. LPA conducted brief interview with S8 during today's visit and reviewed medication log sheet and orders for R1. It was discovered the medication error occurred on 2-14-24 at 6:25pm.

Incident #2: LPA reviewed incident report dated 12-29-23 and updated 1-2-24 involving R1. This is a follow up to a previous case management addressing this incident and conducted on 1-30-24 as well as additional Department follow up thereafter. LPA conducted interviews with S8, S9, and S10 as well as Administrator. LPA also conducted interview with R1. Additional staff interviews were previously conducted on 3-6-24 via telephone. LPA also reviewed a facility internal investigation completed on 1-9-24 regarding the above incident. Based on interviews and record reviews, it was determine that facility concluded a suspicion of a staff member intending to sell medication to other staff members. It was further determined that this incident of facility's discovery was not reported to licensing agency. A copy of the facility's internal investigation was received by the department on 1-30-24. LPA requested copies of employee internal concern forms from December 2023 to be sent by 3-15-24. Administrator was made aware that additional investigation may be required for the above incident. {Cont. on 809C}
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 03/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/12/2024
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 03/12/2024 03:50 PM - It Cannot Be Edited


Created By: Michael Bilger On 03/12/2024 at 01:29 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: 03/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/13/2024
Section Cited
CCR
80075(b)

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80075 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 has already ensured completion of medication staff training on competency in assisting with medications during the dates of 2-21-24, 2-27-24, and 2-28-24 and submitted to LPA.
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Based on interview and record review, R1 did not accurately receive the prescribed medication of Divalproex. This posed an immediate health and safety risk to residents in care.
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Type B
03/22/2024
Section Cited
CCR80061(b)(1)(E)

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80061 Reporting Requirements (b) Upon the occurrence...of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report...shall be submitted to the licensing agency within seven days following the occurrence of such event. (1) Events reported shall include the following: (E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client. This requirement was not met as evidenced by:
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Licensee will ensure completed staff training on regulatory reporting requirements and submit proof of completed training to LPA by POC due date.
Licensee to read regulation 80061 and submit a signed declaration of understanding to LPA by POC due date.
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Based on record review and interview, licensee did not ensure an incident report sent to licensing within 7 days of receiving knowledge of a suspicion of a staff member intending to sell medication to other staff. 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.
SUPERVISOR'S NAME:Liza King
LICENSING EVALUATOR NAME:Michael Bilger
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2024


LIC809 (FAS) - (06/04)
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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: 03/12/2024
NARRATIVE
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As a result of today's case management, citations are issued under Title 22, Division 6 and noted on LIC 809D. Additionally, a civil penalty in the amount of $1000 is issued due to multiple repeat violations of Section 80075(b) within a 12-month period. An exit interview was conducted with S8 and a copy of this report was provided to S8. A copy of LIC 811 will be emailed to Administrator. Appeal rights provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2024
LIC809 (FAS) - (06/04)
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