392700551-5-3-2021-27-AS-LKIG-C2RQBJ-20210506120135

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392700551
Report Date: 04/30/2021
Date Signed: 05/03/2021 11:27:34 AM

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
12/09/2020 and conducted by Evaluator Ashley Boothe

COMPLAINT CONTROL NUMBER: 27-AS-20201209143548

FACILITY NAME:	CAMLU ASSISTED LIVING		FACILITY NUMBER:	392700551
ADMINISTRATOR:	WHITTED, ALMA		FACILITY TYPE:	740
ADDRESS:	6037 N PERSHING AVE		TELEPHONE:	(209) 951-2030
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95207
CAPACITY:	96	CENSUS:	DATE:	04/30/2021
		UNANNOUNCED	TIME BEGAN:	02:55 PM
MET WITH:	Alma Whitted		TIME COMPLETED:	03:05 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility not administering residents' medications as prescribed.
Facility did not assist in arranging for medical care to meet residents' needs.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 4/30/21 at 2:55pm Licensing Program Analyst (LPA) Ashley Boothe contacted Administrator Alma Whitted and stated the pur0pose of the visit to deliver the findings of a complaint investigation with the allegations: facility not administering residents' medications as prescribed and facility did not assist in arranging for medical care to meet residents' needs. A physical visit was not conducted in that the Department is not conducting visits due to COVID-19. Current Census 60.

During the investigation LPA reviewed records and conducted interviews. Based on interview Resident on (R1) goes monthly to a walk in clinic to order triplicate prescription for chronic pain. Appointments are generated monthly on the facility calendar for transportation and escort to the walk in urgent care clinic. Perscriptions are then filled and delivered timely from pharmacy on the same day.

Continued on 9099 C.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 04/30/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2021

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 3

Control Number 27-AS-20201209143548

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: 04/30/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/03/2021 Section Cited CCR 87465(a)(5)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility... (5)The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidence by:	1 2 3 4 5 6 7	The Licensee agrees to submit a written plan of correction to maintain compliance with this regulation at all times to LPA by POC due date 5/3/2021.
	8 9 10 11 12 13 14	Based on records review and interview the licensee did not assist residents with administering medications. R1 ran out of triplicate medication and missed administration for three days which poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 04/30/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 27-AS-20201209143548

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: 04/30/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Continued from 9099.

On one instance (R1) was provided transport to the clinic during R1's calendared time but was not seen by physician to order new prescription. Interviews concluded the clinic was closed and R1 was not seen by a physician timely. LPA reviewed R1's MAR's noted triplicate was not administered for three days after R1 ran out and resumed administration after facility staff rescheduled R1's walk in appointment.

Based on information obtained the aforementioned allegations are SUBSTANTIATED. A finding that the complaint is substantiated means the preponderance of evidence standard has been met, therefore the allegation(s) is found to be substantiated.

Deficiencies are being cited per Title 22 Regulations. Exit interview was conducted with Alma. Copy of the report was sent to via e-mail with a "read receipt" to verify the LIC 9099, 9099 C, 9099 D and Appeal Rights were received. Alma is to print out the report and fax signed copies to LPA at 916-263-4744 or email to LPA at ashley.boothe@dss.ca.gov.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 04/30/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3