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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700551
Report Date: 08/31/2021
Date Signed: 08/31/2021 02:33:18 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/31/2021 and conducted by Evaluator Ashley Boothe
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20210831081051
FACILITY NAME:CAMLU ASSISTED LIVINGFACILITY NUMBER:
392700551
ADMINISTRATOR:WHITTED, ALMAFACILITY TYPE:
740
ADDRESS:6037 N PERSHING AVETELEPHONE:
(209) 951-2030
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY:96CENSUS: 58DATE:
08/31/2021
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Alma WhittedTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Facilty failed to notify CCL of covid positive status of building
INVESTIGATION FINDINGS:
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On 8/31/2021 at 11am, Licensing Program Analyst (LPA) Ashley Boothe arrived unannounced to open a 10 day complaint investigation with the following allegation:Facilty failed to notify CCL of covid positive status of building. LPA met with Administrator and explained the purpose of today’s visit. LPA was allowed entry into the facility, current census is 58.

As of today Resident one (R1) tested positive at hospital and facility was notified of positive status upon discharge. R1 has completed isolation period. The facility did not to report COVID positive resident to CCL.

Based on information obtained the aforementioned allegations are SUBSTANTIATED. A finding that the complaint is substantiated means the preponderance of evidence standard has been met, therefore the allegation(s) is found to be substantiated.

Per California Code of Regulations (CCRs) - Title 22, Division 6, the following deficiencies are being cited on the attached 9099D. The Administrator was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. Exit interview and a copy of report was given.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 27-AS-20210831081051
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: CAMLU ASSISTED LIVING
FACILITY NUMBER: 392700551
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/14/2021
Section Cited
CCR
87211(a)(2)
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Reporting Requirements (a) ... (2)Occurrences, such as epidemic outbreaks,...which threaten the welfare, safety or health of residents... shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. This requirement not met as evidence by:
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The licensee agrees to submit a written declaration to maintain compliance with this regulation at all times to LPA by POC due date.
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Based on observation, interview, and record review the licensee did not report R1 reported as COVID positive during admission to hospital or upon return to the facility to CCL or LHD which poses a potential health and safety risk to residents 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 KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2021
LIC9099 (FAS) - (06/04)
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