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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701177
Report Date: 10/16/2024
Date Signed: 10/16/2024 04:21:26 PM

Document Has Been Signed on 10/16/2024 04:21 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:
10/16/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Danica MorrisonTIME VISIT/
INSPECTION COMPLETED:
04:40 PM
NARRATIVE
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On 10-16-24 at 2:00pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding previously reported incident involving medication and restraint practices. LPA met with Administrator Danica Morrison and explained the purpose of the visit. LPA conducted brief interview with Administrator and reviewed incident reports dated 9/10/24 and 10/3/24. LPA also reviewed individualized program plan (IPP) for resident2 (R2).

Incident #1: Based on interview and record review, on 9/10/24 it was discovered by facility that multiple medications for resident1 (R1) which included Clonidine HCL 0.1mg, Lactulose 10mg/15mL, and Psyllium Husk 100% powder were not given by Staff1 (S1) to R1 per Physician's orders on 9/9/24. Record review also states medication log sheets indicated medication was not given. It was revealed that facility staff notified R1's Physician accordingly and followed additional instructions given. Incident report reviewed revealed staff member missed giving medication to R1 due to an "oversight."

Incident #2: Based on interview and record review, on 10/3/24 at approximately 3:45pm, R2 engaged in high risk behavior which included grabbing, swinging, and spitting at staff. Staff on duty attempted to redirect R2 to another room but were unsuccessful. S2 attempted to verbally redirect R2 but was unsuccessful and R2 continued behaviors of hitting and spitting at staff. Interview and record review revealed S2 then lifted R2 up and escorted R2 out the front door of facility. Facility staff on duty notified Administrator and Physician. Staff received and followed additional instructions from Physician. R2 was not injured during the process of this transfer procedure. It was determined through interview that this lift procedure was not an approved procedure according to training and facility protocol. Additional record review revealed S2 received proper training on de-escalation and crisis prevention intervention prior to this incident.

Additional incident reports were reviewed by LPA during this visit regarding R2 and on-going behaviors exhibited at facility. Incident reports include the dates of 9/4/24 and 9/5/24 and described behaviors exhibited by R2 as hitting, spitting and yelling at staff. {Cont. on 809C}
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/16/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: 10/16/2024
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Based on record review and interview, it was determined that behavior interventions are in place for R2 and updated in R2's individualized program plan (IPP). Additional staff training on behavior de-escalation has been completed as of 10/11/24

As a result of today's case management, citations are issued under Title 22, Division 6. Two additional civil penalties in the amounts of $250 each are issued in addition to citations due to repeat violations of Sections 80075(b) and 80078(a) within a 12-month period. An exit interview was conducted with Administrator and a copy of this report was provided to Administrator. Appeal rights provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/16/2024 04:21 PM - It Cannot Be Edited


Created By: Michael Bilger On 10/16/2024 at 03:12 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: 10/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/17/2024
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 medication procedures to include but not be limited to: Proper documentation and following Physician orders. Training date to be submitted to LPA by POC due date. Proof of completed training to be submitted to LPA by 10-31-24.
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Based on interview and record review, Licensee did not ensure the above requirement in that facility staff did not assist R1 with mulitiple medications as prescribed. This posed an immediate health and safety risk to resident in care.
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Type B
10/28/2024
Section Cited
CCR80078(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 has completed a plan of correction which includes additional staff training on crisis safety completed on 10-11-24
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Based on interview and record review, Licensee did not ensure proper care and supervision of R2 in that facility staff uitlized an improper and non-approved restraint procedure during a de-escallation attempt. This posed a potential health, safety, and resident rights risk to resident 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: 10/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2024


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