392700551-6-16-2021-27-AS-ABOE-C42TN6-20210616145210

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392700551
Report Date: 06/16/2021
Date Signed: 06/16/2021 02:52:29 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 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: 60	DATE:	06/16/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Alma Whitted		TIME COMPLETED:	03:00 PM

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	On 06/16/2021 at 8am, Licensing Program Analyst (LPA) Ashley Boothe spoke with facility staff regarding facility risk assessment questions who confirmed no staff or clients have experienced symptoms within the last 10 days. At 11am, LPA arrived unannounced to conduct a required 1-year Annual inspection. LPA met with Administrator, Alma Whitted and explained the purpose of today’s inspection. LPA was allowed entry into the facility that is licensed to serve a total capacity of 96, today's census is 60, 4 hospice residents. LPA interacted with a random number of residents during this visit and observed residents engaging in communal dining and activities. The physical plant was toured inside and outside to ensure the safety of the residents. LPA observed resident rooms, restrooms, medications room, dining room, communal areas, patio, kitchen, staff offices, and common restrooms. LPA observed facility last conducted disaster drill on 6/14/2021. The temperature inside the facility was measured at between 74F and 76F which is within the required range of 68F and 85F, or in areas of extreme heat the maximum shall be 30 F less than the outside temperature. The hot water was measured at 111F which is not less than 105F and not more than 120 F. LPA observed the centrally stored medications area to be locked and inaccessible to residents. LPA observed R1's MAR to prescribe Tylenol twice daily, S1 stated medications were administered from house supply. LPA did not observe Tylenol properly labeled and stored for R1's use. The first aid kit was found in compliance containing: a current edition of a first aid manual, sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, and Antiseptic solution. LPA observed a pull alarm system, fire extinguisher inspected on 8/14/2020, smoke and carbon monoxide detectors. LPA observed central heating and air in the facility is non operational, repair work is scheduled and all residents rooms and staff areas have portable air conditioning units and fans in working order to maintain temperature in the facility within regulatory range. LPA 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. LPA observed knives and toxins inaccessible to residents.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2021

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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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: 06/16/2021

NARRATIVE

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Continued from 809.

Upon a file review the following items were discussed to be submitted with any changes annually to be submitted by 6/30/2021.
Designation of Administrative Responsibility LIC308
Personnel Report LIC500
Administrator Certificate expire on 10/21/2021
Emergency Disaster Plan LIC610E
Transportation Plan
First aid/CPR certificates

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 and a copy of report was given.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2021

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: 06/16/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87564(e)

Incidental Medical and Dental (e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information... This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above in that R1 was administered Tylenol from house supply of medications not labeled for R1 out of which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/30/2021
	Plan of Correction
1 2 3 4	The Licensee agrees submit proof of labeled medications to LPA by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: 06/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2021

LIC809 (FAS) - (06/04)

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