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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701177
Report Date: 12/31/2024
Date Signed: 12/31/2024 12:36:36 PM

Document Has Been Signed on 12/31/2024 12:36 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:
12/31/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:56 AM
MET WITH:Danica MorrisonTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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On 12-31-24 at 9:56am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding multiple reported incidents. LPA met with Program Administrator (PA) Danica Morrison and explained the purpose of the visit. LPA conducted brief interview with PA and reviewed incident reports dated between 12-11-24 to 12-30-24. LPA also reviewed staff training documentation and current service plans for resident1 (R1) and R2.

Incident #1: On 12-10-24 at approximately 3:00pm, resident2 (R2) engaged in grabbing staff in the chest area. Staff on duty attempted to redirect R2 to an area away from others for de-escalation purposes. During this attempt, Staff2 (S2) began walking towards PA and was redirected again by staff using a turnaway technique to prevent potential injury and escalated behaviors.

Incident #2: On 12-28-24 at approximately 7:40am: Resident1 (R1) engaged in combativeness with a staff member. Staff5 (S5) stepped in to use crisis preventative institute (CPI) disengagement strategies while additional staff used verbal redirection. R1 continued to engage in various property destruction, and S3 utilized a CPI low level turn away procedures at various points of the interaction for safety purposes. R1 returned to baseline behavior within 30 minutes of the de-escalation techniques. Medications were given to R1 per physician's orders to aid in de-escalation.

Incident #3: On 12-29-24 at approximately 5:45pm, R1 became fixated on a staff member and was verbally redirected by another staff member on duty. At approximately 9:00pm, R1 became combative with staff. Medications were given by staff per physician's orders. At approximately 9:55pm, R1 began chasing staff with a mop and was verbally redirected by staff. Shortly thereafter, according to incident report, R1 continued to hit and spit at staff, and at approximately 10:15pm, S1 and S2 placed R1 in a medium level standing hold for approximately 30 seconds. R1 then returned to baseline behavior shortly after the hold according to incident report. {Cont. on 809C}
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 12/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/31/2024
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: 12/31/2024
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Incidents described above were accompanied by debriefing reports which included a summary of the events and interventions used, as well as additional interventions to be used for any future events. All staff members involved in the events were noted in the debriefing. Service plans have been updated for R1 and R2 to reflect behaviors with interventions in place. No injuries occurred to R1 and R2 in relation to these events. LPA verified current CPI certification of staff members involved in the events.

Incident #4: On 12/11/24 at approximately 8pm, a staff member on duty noticed a discrepancy in the medication count and notified supervisor on duty. During this conversation, it was discovered that S3 made an oversight passing R1's 3:00pm medication and confirmed that medication Guanfacine 1mg was given instead of the prescribed medication Clonidine HCL 0.1mg. R1's prescribing physician was notified about the medication error who gave feedback and instructions to staff. R1 was monitored throughout the evening to ensure normal vitals and overall health and safety. No adverse reactions reported as a result of this medication error.

As a result of today's case management, citation is issued under Title 22, Division 6. A civil penalty in the amount of $250 is issued in addition to citation due to repeat violation of Section 80075(b) within a 12-month period. An exit interview was conducted with PA and a copy of this report was provided. Appeal rights provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 12/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2024
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Document Has Been Signed on 12/31/2024 12:36 PM - It Cannot Be Edited


Created By: Michael Bilger On 12/31/2024 at 12:04 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: 12/31/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/14/2025
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 additional oversight of staff by designating appropriate individual to conduct medication shadowing. Trainer to be a licensed professional. Licensee to document frequency of shadowing and submit completed results to LPA by POC due date.
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Based on interview and record review, R1 was given wrong prescribed medication by staff member. This posed a potential health and safety 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: 12/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/31/2024


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