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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700551
Report Date: 12/16/2021
Date Signed: 12/16/2021 05:02:57 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:
12/16/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
04:35 PM
MET WITH:Alma WhittedTIME COMPLETED:
05:15 PM
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On 12-16-21 at 4:35pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit for an incident that occurred on 11/29/21. LPA met with Administrator Alma Whitted and explained the purpose of the visit. LPA reviewed incident report and needs and appraisal form for resident1 (R1) LPA also interviewed Administrator and Resident Care Coordinator (RCC). Based on interview and record reviews, it was determined that R1 exited facility at approximately 7:30am on 11/29/21 with attempts by staff to be redirected. R1 became physically combative with staff. Staff continued to supervise R1 during incident. Based on record review and interview, staff called 911; police and ambulance arrived. Ambulance transported R1 to hospital for further evaluation.

LPA reviewed appraisal needs and service plan with Administrator which revealed an update to address R1's history of exit seeking and appropriate interventions in place for prevention.

Based on interviews and record reviews, facility staff followed procedures for redirecting R1 along with reporting requirements and appraisal needs updating as appropriate. As a result, the department has closed this case management.

No deficiencies cited during today's visit. An exit interview was conducted 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: 12/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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