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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701177
Report Date: 02/09/2023
Date Signed: 02/09/2023 12:51:29 PM

Document Has Been Signed on 02/09/2023 12:51 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:
(510) 621-9064
CITY:STOCKTONSTATE: CAZIP CODE:
95215
CAPACITY: 4CENSUS: 2DATE:
02/09/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Athika KaroliaTIME COMPLETED:
01:00 PM
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On 2/9/23 at approximately 10am Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a case management related to incident reports reporting use of restraints. LPA Maja Jensen met with Administrator Athika Karolia and explained the purpose of today's visit. Sylvia Pinto withe Valley Medical Regional Center QBMP was also present.

There have been several incident reports related to the use of restraints which should be reserved for incidents that present imminent danger or in an attempt to prevent self injurious behavior. The Department has received multiple Incident Reports detailing use of restraints for resident 1 (R1). LPA Jensen interviewed the Administrator and the Regional Center representative. LPA Jensen also reviewed the resident file for R1. The facility has been following Resident 1's (R1's) Individual Behavior Support Plan (IBSP) as it is currently written however there will be a review conducted by the Behavior Modification Review Committee with the Regional Center of the East Bay in order to determine of changes are warranted to the listed Consequence Strategies related to High Risk Behavior encounters. Once this review is complete the Administrator agrees to notify Community Care Licensing if any changes to Consequence Strategies will be implemented or of the current protocol will remain in place.

The Administrator advised that frequency of use of restraints has decreased for resident 2 and she attributes this to a change in medication which occurred approximately 3 weeks ago. The facility has also contracted with a medical specialist in the field of brain injury and use of restraints for consulting services.

LPA Jensen also discussed staff qualifications with the Administrator and determined that facility personnel are in compliance with California Code of Regulations (CCR) Title 22, Division 6, section 89965.

An exit interview was conducted and a copy of this report was provided.


SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 02/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/09/2023
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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