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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701177
Report Date: 01/30/2024
Date Signed: 01/30/2024 04:00:30 PM

Document Has Been Signed on 01/30/2024 04:00 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:MONTEL JENNINGSFACILITY TYPE:
737
ADDRESS:1775 WHITE LANETELEPHONE:
(510) 621-9064
CITY:STOCKTONSTATE: CAZIP CODE:
95215
CAPACITY: 4CENSUS: 2DATE:
01/30/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Danica MorrisonTIME COMPLETED:
04:15 PM
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On 1-30-23 at 3:00pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit. LPA met with Administrator Danica Morrison and explained the purpose of the visit. The purpose of today's case management was to obtain various documentation for resident1 (R1) regarding a previously reported incident involving a substance found in R1. Documentation collected included the following: Emergency Identification information, physician's report, individualized program plan (IPP), medication list, hospital discharge paperwork, face sheet, sign in/out sheets, and staff schedule. A brief interview was conducted with Administrator and Administrator was informed that additional investigation by the department may continue.

An exit interview was conducted with Danica Morrison and a copy of this report was provided to Danica.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/30/2024
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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