<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701177
Report Date: 10/04/2023
Date Signed: 10/04/2023 12:20:48 PM

Document Has Been Signed on 10/04/2023 12:20 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: 3DATE:
10/04/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Athika KaroliaTIME COMPLETED:
12:20 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 10-4-23 at 10:30am, Licensing Program Analysts (LPAs) Michael Bilger and Arvin Villanueva arrived unannounced to conduct a case management visit regarding an incident reported on 10-2-23. LPAs met with Administrator Athika Karolia and explained the purpose of the visit. LPAs briefly interviewed Administrator and reviewed incident report with Administrator. Based on interview and record review, it was determined that on 10-1-23 at approximately 9:00am, resident1 (R1) was verbally expressing a desire to leave facility and engaged in behavior which consisted of yelling and combativeness towards staff and other residents. Additionally, incident report states R1 verbalized threats of attempting to exit facility, but was successfully redirected back to facility multiple times. During R1's behavior display, R1 charged and hit another resident and threatened to attack staff on duty. At approximately 10:36am, facility staff called 911 and R1 was transported to the hospital due to threats of harming self and others. Incident was reported within regulatory time frames.

LPA reviewed R1's facility file documentation and determined a needs and service plan is updated to reflect current behaviors and associated interventions including verbal de-esclations. Staffing files were reviewed to ensure updated and required training and certifications.

As a result of today's case management, no citations are issued. An exit interview was conducted with Athika Karolia and a copy of this report was provided to Athika.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 10/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1