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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700551
Report Date: 10/15/2021
Date Signed: 10/15/2021 06:08:33 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: 56DATE:
10/15/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Alam WhitteTIME COMPLETED:
06:20 PM
NARRATIVE
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On 10/15/2021 at 1:10pm, Licensing Program Analyst (LPA) Ashley Boothe, arrived unannounced to conduct a conduct a Health and Safety Visit. LPA met with Administrator and explained the purpose of today’s inspection. Administrator was unavailable in a meeting during LPA's visit and gave verbal designation for Designee Staff one (S1) to accompany LPA during today's inspection. Current Census is 56 of which 6 are hospice. LPA observed resident roster last updated on 8/22/2021. LPA observed Administrator Certificate expires on 10/10/2021. 4 of 4 staff observed with criminal record clearance associated in the Licensing Information System (LIS).

LPA and S1 toured the facility inside and outside to ensure the safety of the residents, interacted with a random number of residents during this visit and observed residents engaged in dining and games in communal living room. Observed resident rooms, restrooms, medications room, dining room, communal areas, patio, kitchen, and staff offices. The temperature inside the facility was measured at 76*F which is within the required range of 68*F and 85*F, or in areas of extreme heat the maximum shall be 30 *F less than the outside temperature. Observed air conditioning system not in working order and plan in place all residents have access to individual air conditioning units to be maintained in working order at all times. The heater repaired on 10/14/2021 faulty switch replaced found to be in working order. The hot water was measured between 110 and 113 *F which is not less than 105*F and not more than 120 *F. Resident's Personal Rights, Resident Counsel, and Let Us Know posting in main area accessible to all residents, family, visitors, and staff. Observed fire extinguisher last inspected on 8/15/2021, pull alarm system, and smoke and carbon monoxide detectors. Fire sprinkler system last inspected on 9/2/2021.

Observed fire extinguisher last inspected on 8/15/2021, pull alarm system, and smoke. Fire sprinkler system last inspected on 9/2/2021.



Continued on 809.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2021
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 5
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
VISIT DATE: 10/15/2021
NARRATIVE
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Continued from 809.

Observed food supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days which shall be maintained on the premises at all times. Kitchen Staff two (S2) is current with serve safe certification. Hand washing sink with soap, paper towels, hand washing sign, and covered trashcan.. Hot water signs posted to notify of water above regulatory range. Refrigerator and freezer temperatures were within adequate range per regulations. Observed knives inaccessible to residents.

Observed dining room with tables and chair setup for social distancing and communal meals and small group activities.

Observed south corridor second floor inaccessible to residents with stripped dry wall and flooring. Administrator stated second floor repair work completion is expected 60 days. Observed two of two storage rooms unlocked and accessible to residents housing paint and construction supplies. Observed residents rooms under construction with signs posted "do not enter" but door handles removed, not in good repair with exposed wires and piping. Observed ceiling tiles missing on first floor south corridor and north corridor damaged wall from water fountain removal. Observed carbon monoxide detectors not in working order or removed. Observed two window screens off window on first floor. Observed outside a pile of loose bricks, fallen tree branch, and shed not in good repair on the facility property.

Observed the centrally stored medications area to be locked and inaccessible to residents. Observed medications room, three of three medications counted matched MAR's and Centrally Stored Log. Observed PRN documented. Observed Resident one (R1) with bedrails and no physician's order filed. One of three resident files reviewed with no current admissions agreement on file for the facility.

Observed call system in working order but Staff three(S3) stated they did not have a phone or access to a phone since starting two and a half months ago. Staff four (S4) phone in working order. Observed staff did not respond to two calls to second floor rooms and S3 responded to S1 on the walkie talkie 7 minutes after pull cord was activated. Observed no chairlifts in the three stairwells and S1 stated unaware if any were on site. Observed resident room 106 to use oxygen and no signs posted to demark.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2021
LIC809 (FAS) - (06/04)
Page: 2 of 5
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: 10/15/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/27/2021
Section Cited

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(3) Ensuring that the use of oxygen equipment meets the following requirements: (B) “No Smoking-Oxygen in Use” signs shall be posted in the appropriate areas.

This requirement is not met as evidenced by:
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Based on observation and interview, the licensee did not comply with the section cited above in that there was no "Oxygen in use" signs posted while R1 observed using oxygen in their room which poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
10/27/2021
Section Cited

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(a) Postural supports may be used under the following conditions. (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record.


This requirement is not met as evidenced by:
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Based on observation and interview, the licensee did not comply with the section cited above in that R1 did not have a phycians order for bed rails which poses/posed a potential health, safety or personal rights risk to persons 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: 10/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2021
LIC809 (FAS) - (06/04)
Page: 3 of 5
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: 10/15/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/16/2021
Section Cited

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1569.695(f)(1) Emergency Plans (f)(1) An evacuation chair at each stairwell on or before July 1,2019. This requirement is not met as evidence by:
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Based on observation and interview the licensee did not ensure an evacuation chair at each stairwell in the facility which poses an immediate health and safety risk to residents in care.
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Type A
10/16/2021
Section Cited

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... carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections. This requirement is not met as evidenced by:
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Based on observation and interview the licensee did not ensure working carbon monoxide detectors in the facility which poses an immediate 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: 10/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2021
LIC809 (FAS) - (06/04)
Page: 4 of 5
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
VISIT DATE: 10/15/2021
NARRATIVE
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Continued from 809 C.

POC for deficiency cited under Title 22 87309(a) and 87303(a) extension to POC due date has been approved in that repair work estimated completion is 60 days. POC extended 60 days to 12/15/2021.

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, copy of report given.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2021
LIC809 (FAS) - (06/04)
Page: 5 of 5