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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700551
Report Date: 11/02/2020
Date Signed: 11/02/2020 02:50:48 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
04/06/2020 and conducted by Evaluator Avelina Martinez
COMPLAINT CONTROL NUMBER: 27-AS-20200406141810
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: 70DATE:
11/02/2020
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Alma WhittedTIME COMPLETED:
02:50 PM
ALLEGATION(S):
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Resident is in need of higher level of care.
Lack of supervision results in a resident threatening another resident.
Facility staff failed to meet the resident's needs.
INVESTIGATION FINDINGS:
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Licensing Program Analyst Avelina Martinez contacted the facility via telephone to commence a complaint investigation via telephone on 11/02/2020 due to COVID-19 and pre-cautionary measures. LPA identified herself and discussed the purpose of the call and the elements of the allegations with Alma Whitted.

Throughout the investigation, LPA Martinez reviewed Medical records, conducted interviews. During the medical records review, LPA learned resident 1 (R1) is independent with activities of daily living. R1 is able to leave the facility unassisted. Furthermore, R1 able to communicate needs. R1's current Health Certification form does not state R1 needs a higher level of care.

Continued..
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 263-4809
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2020
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-20200406141810
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: 11/02/2020
NARRATIVE
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Furthermore, the facility is following up on R1's health needs. The Facility is in contact with the resident's primary physician and VA physicians. Throughout the investigation, LPA learned staffing was adequate. Staff 1 (S1) reported there were no issues with staffing. Due to the above noted information, although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, and therefore the allegation is unsubstantiated

An exit interview was conducted with Alma Whitted via telephone and a copy of this report was provided to Alma Whitted via email and an electronic email read receipt confirms receiving these documents.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 263-4809
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2020
LIC9099 (FAS) - (06/04)
Page: 2 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
04/06/2020 and conducted by Evaluator Avelina Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20200406141810

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: 70DATE:
11/02/2020
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Alma WhittedTIME COMPLETED:
02:50 PM
ALLEGATION(S):
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2
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9
Facility failed to provide a safe, comfortable environment for residents.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Avelina Martinez contacted the facility via telephone to commence a complaint investigation on 11/02/2020 due to COVID-19 and pre-cautionary measures. LPA identified herself and discussed the purpose of the call and the elements of the allegations with Alma Whitted.

During this investigation, LPA Martinez reviewed facility records and conducted interviews. Moreover, resident 2, resident 3, resident 4, reported the facility being an uncomfortable and unsafe environment due to resident 1's inappropriate behaviors towards residents and employees. On various occasions, resident 1 displayed and/or engaged in inappropriate behavior. It was reported resident 1 verbally abused residents and employees. Staff 1 reported 3 residents verbalized being afraid of resident 1.

Continued..
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 263-4809
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20200406141810
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: 11/02/2020
NARRATIVE
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Furthermore, Resident 1's Needs and Service Plan did not include how facility staff will keep other residents safe when resident 1 becomes aggressive. The licensee did not ensure to provide a safe and comfortable environment for the other residents residing at this facility.

As a result of this investigation, the Department finds this allegation to be Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiency cited on the LIC 9099-D, per Title 22 Regulations. Appeals rights given to the facility.


An exit interview was conducted with Alma Whitted via telephone and a copy of this report was provided to Alma Whitted via email and an electronic email read receipt confirms receiving these documents.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 263-4809
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2020
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20200406141810
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: 11/02/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/03/2020
Section Cited
CCR
7468.1(2)(3)
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7468.1Personal Rights of Residents in All Facilities:(2)To be accorded safe, healthful...accommodations(3)To be free from...intimidation, abuse...This requirement was not met as evidence by.
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The administrator agrees to: conduct a staff in-service training on: aggressive behaviors and how to assist residents with aggressive behaviors. LPA will email in-service training plan to LPA by 11/04/2020.
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Based on interviews and facility documents the licensee did not ensure R2 thru R4 were accorded safe, healthful and comfortable accommodations. This posed an immediate health and safety risk to residents in care.
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Administrator will email training materials and sign in sheet to LPA by 11/30/2020.
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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: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 263-4809
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2020
LIC9099 (FAS) - (06/04)
Page: 5 of 5