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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700551
Report Date: 09/16/2021
Date Signed: 09/16/2021 12:20:40 PM

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: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:
09/16/2021
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Alma WhittedTIME COMPLETED:
12:30 PM
NARRATIVE
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On 09/16/2021 at 10am, Licensing Program Analyst (LPA) Ashley Boothe arrived unannounced to conduct a visit in accordance with the stipulation order effective July 2, 2019. LPA met with Administrator and explained the purpose of today’s inspection. LPA was allowed entry into the facility that is licensed to serve a total capacity of 96 residents. Current Census is 58 of which 4 are Hospice.

The physical plant was toured inside to ensure the safety of the residents. LPA observed resident rooms, restrooms, medications room, communal areas, and staff office. LPA reviewed Incident Reports submitted to the Regional Office found to be compliance at this time. LPA reviewed personnel files found to be compliance at this time. LPA observed that medications are properly stored and kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medications. LPA observed the facility is clean and sanitary, but not in good repair at this time in that there was a major leak in the roof causing damage to walls, floors, electrical, and ceilings in the second floor south corridor and multiple resident rooms. Residents will be relocated to the second floor north corridor while work repairs are completed. LPA observed room 107 and room 111 doors were left open exposing rooms under construction with exposed wiring, tools, and building material accessible to residents. LPA measure temperature to be between 68 *F and 74*F within regulatory range of 68*F to 85*F. LPA reviewed one of one residents with restricted health condition, needs and services plans and care plan last updated on 7/05/2021. LPA reviewed monthly training logs including record keeping, ADL's, COVID, fire drill, wheelchairs and ambulatory aides, sun downing, and postural supports. LPA observed last training completed on 8/28/2021 and next training's scheduled for 9/24/2021.

Per California Code of Regulations (CCRs) - Title 22, Division 6, the following deficiencies are being cited on the attached 809D during this visit. Civil penalties shall be assessed when the licensee fails to correct the violation and any appropriate extensions to the plan of correction due date. The Licensee was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. Exit interview held and a copy of report was given.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 09/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/14/2021
Section Cited

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Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidence by:
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Based on observation rooms 107 and room 111 doors were left open exposing rooms under construction with exposed wiring, tools, and building material accessible to residents which poses a potential health and safety risk to residents in care.
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Type B
10/14/2021
Section Cited

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Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidence by:
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Based on observation, interview and records review the facility is not in good repair in that there was a major leak in the roof causing damage to walls, floor, electrical, and cielings in the second floor south cooridor and several resident rooms 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: 09/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2021
LIC809 (FAS) - (06/04)
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