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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701177
Report Date: 11/02/2023
Date Signed: 11/02/2023 03:49:14 PM

Document Has Been Signed on 11/02/2023 03:49 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:MONTEL JENNINGSFACILITY TYPE:
737
ADDRESS:1775 WHITE LANETELEPHONE:
(510) 621-9064
CITY:STOCKTONSTATE: CAZIP CODE:
95215
CAPACITY: 4CENSUS: 3DATE:
11/02/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Brandon BatyTIME COMPLETED:
04:00 PM
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On 11-2-23 at 2:15pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding multiple incident reports for resident1 (R1). LPA met with Direct Care Supervisor (DCS) Brandon Baty and explained the purpose of the visit. LPA reviewed incident reports dated 10-24-23 and 10-26-23 and conducted brief interview with DCS. On both dates mentioned above, R1's behaviors escalated and included attempting to elope and run into the street. Staff on duty followed R1 and notified police simultaneously due to difficulty in redirecting R1. R1 was admitted to local hospital and returned to facility within 24 hours. On 11-1-23 at approximately 10:00pm, R1 attempted to elope by pushing screens out of facility windows. R1 ran down the street for nearly a mile while followed by facility staff with attempts to redirect. Police were notified of this incident and R1 was admitted to local hospital with expected return on 11-2-23. Behavioral plan and individualized program plan (IPP) have been updated to reflect behaviors noted above. Currently facility has a total of seven staff on duty which includes 2 staff assigned to R1. Additionally, facility is attempting to relocate R1 to an alternative environment and for various interventions. Incident noted above were reported to licensing within regulatory time frames. LPA also discussed procedures for 3-day and 30-day eviction options with DCS, and purposes of on-going updated documentation of behaviors and associated interventions. All staff members involved in the above incidents are certified under crisis prevention institute (CPI).

As a result of today's case management, no citations are issued. An exit interview was conducted with Brandon Baty and a copy of this report was provided to Brandon.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/02/2023
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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