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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700551
Report Date: 11/19/2021
Date Signed: 11/19/2021 02:42:40 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
11/09/2021 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20211109153125
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: 57DATE:
11/19/2021
UNANNOUNCEDTIME BEGAN:
01:12 PM
MET WITH:Alma WhittedTIME COMPLETED:
01:58 PM
ALLEGATION(S):
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5
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9
Facility has bed bugs
Staff not properly trained
INVESTIGATION FINDINGS:
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On 11-19-21 at 1:12pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver findings for the complaint allegations noted above. LPA met with Administrator Alma Whitted and explained the purpose of the visit. Throughout this investigation, LPA interviewed four residents, reviewed six staff records, interviewed pest control representative, interviewed resident care coordinator, interviewed Administrator, reviewed facility file documentation, and conducted observation of facility throughout.

Allegation: Facility had bed bugs: LPA interviewed resident care coordinator (RCC) who stated facility contacted pest control services to investigate possible bed bug infestation. LPA reviewed pest control service agreement which stated a service date of 11-10-21 with a treatment date scheduled for 11-17-21. LPA also interviewed Resident1 (R1), R2, R3, and R4, and observed facility hallways and R1-R4’s rooms. LPA also interviewed pest control service representative on 11-16-21 and it was revealed that a bed bug was found in R2’s room and evidence of a bed bug was found in R3’s room. Pest control representative sent a photo to LPA on 11-16-21 as confirmation of findings.

{Cont. on 9099C}
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2021
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 5
Control Number 27-AS-20211109153125
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
VISIT DATE: 11/19/2021
NARRATIVE
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LPA interviewed Administrator on 11-17-21 and it was revealed that a pest control company services facility regularly but not specific to bed bugs, in which another company is used should bed bugs occur. Additionally, based on interviews, it was revealed that facility has a history of bed bug occurrence. Based on the interviews conducted, records reviewed, and observations, it is determined that the preponderance of evidence standard is met, and therefore this allegation is SUBSTANTIATED.

Allegation: Staff not properly trained. LPA interviewed resident care coordinator (RCC) and reviewed six caregiver staffing records. Based on interview and records reviewed, it was determined that Staff5 (S5) did not complete required initial training requirement after a hire date of 8-18-21. Additionally, Staff6 (S6) did not complete required initial training requirement after a hire date of 10-21-21. Based on interview and records reviewed, 2 of 6 staffing records did not contain required training documentation to prove training was completed. The preponderance of evidence standard is met, therefore this allegation is SUBSTANTIATED.

Deficiencies are cited today on LIC 9099D per Title 22, Division 6, Chapter 8 and Health and Safety Code, Chapter 3.2. An exit interview was conducted with Alma Whitted and a copy of this report was provided to Alma. Appeal Rights provided.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20211109153125
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: 11/19/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/29/2021
Section Cited
CCR
80087(a)(1)
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Buildings and Grounds (a) The facility shall be clean, safe, sanitary and in good repair at all times…(1) The licensee shall take measure to keep the facility free of flies and other insects. This requirement is not met as evidenced by:
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Licensee will arrange for routine pest control service to include targeting bed bugs, provided by licensed pest control agency. Licensee to submit copy of service agreement to LPA by POC due date.
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Based on interview, observation, and record review a bed bug was located in R2’s room. Additionally, facility did not arrange for routine pest control treatment specific to bed bug occurrence after a previous history of bed bug occurrence. This poses a potential health, safety, and resident rights risk to residents in care.
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Type B
11/29/2021
Section Cited
HSC
1569.625(b)(1)
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Training shall consist of 40 hours training. A staff member shall complete 20 hours…before working independently with residents. The remaining 20 hours…shall be completed within the first four weeks of employment. This requirement is not met as evidenced by:
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 Licensee will audit staffing charts and develop a plan to ensure all required staff training is completed timely and as appropriate. Plan to be submitted to LPA by POC due date.

Licensee to submit proof of completed training for S5 and S6 to LPA by POC due date.
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Based on record review and interview S5 did not complete 40 hours within 4 weeks of hire; S6 did not complete 20 hours before working independently with residents. This poses a potential health, safety, and resident rights 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: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
11/09/2021 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20211109153125

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: 57DATE:
11/19/2021
UNANNOUNCEDTIME BEGAN:
01:12 PM
MET WITH:Alma WhittedTIME COMPLETED:
01:58 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility has scabies outbreak
INVESTIGATION FINDINGS:
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12
13
On 11-19-21 at 1:12pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver findings for the complaint allegation noted above. LPA met with Administrator Alma Whitted and explained the purpose of the visit. Throughout this investigation, LPA interviewed four residents, interviewed resident care coordinator, reviewed facility file documentation, and conducted observation of facility throughout.

LPA interviewed resident care coordinator (RCC) and Resident2 (R2). LPA also reviewed physician’s order for R2, incident report for R2, medical assessment record (MAR) for R2, and observed room of R2. Based on interviews and records reviewed it is determined that R2 developed redness and itching on 11-9-21, and facility notified hospice for intervention. Based on interview, it was revealed that scabies could not be positively identified by hospice nurse and hospice physician. A physician’s order for medication was received by facility from hospice on 11-9-21 to treat skin condition of R2 and medication was started on 11-9-21 at 8:00pm as per physician’s order by facility staff. {Cont. on 9099C}
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20211109153125
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
VISIT DATE: 11/19/2021
NARRATIVE
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2
3
4
5
6
7
8
9
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LPA observed R2s room as a single room occupancy, and to contain appropriate signage for isolation purposes. LPA also observed an isolation cart outside of room. Based on observation, record review, and interview, facility acted timely in identifying skin condition.

It is determined that the preponderance of evidence standard is not met, therefore this allegation is USUBSTANTIATED.

An exit interview was held with Alma Whitted and a copy of this report was left with Alma.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5