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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700997
Report Date: 04/15/2022
Date Signed: 04/15/2022 04:29:14 PM


Document Has Been Signed on 04/15/2022 04:29 PM - It Cannot Be Edited

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:
392700997
ADMINISTRATOR:WHITTED, ALMAFACILITY TYPE:
740
ADDRESS:6037 N. PERSHING AVENUETELEPHONE:
(209) 951-2030
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY:160CENSUS: 47DATE:
04/15/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Andrea EldridgeTIME COMPLETED:
04:35 PM
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On 4-15-22 at 3:00pm, Licensing Program Analysts (LPAs) Michael Bilger and Maja Jensen arrived unannounced to conduct a case management visit for an incident reported on 3-3-22 which occurred on 3-2-22.. LPA met with Resident Care Coordinator (RCC) and explained the purpose of the visit. Administrator Alma Whitted was informed of LPAs visit and gave permission for Andrea to sign in her absence and accommodate LPAs. LPAs reviewed incident report with RCC and interviewed RCC. Based on record review and interview it was determined that Resident1 (R1) was sent to the hospital on 3-2-22 after experiencing shortness of breath and a fall while in the shower. R1s shortness of breath and fall occurred at 12:30pm on 3-2-22 and 9-1-1 was notified by staff. R1 was then transported to acute hospital at approximately 1:00pm and officially admitted on 3-3-22. R1 remained in hospital until 3/14/22 at which time R1 was transferred back to facility and began receiving hospice services on 3/14/22.

On 3-22-22, licensing department received a death report stating R1 expired on 3/19/22 while under hospice care due to acute cebrol vascular stroke. Based on record review it was determined that reporting requirements and emergency procedures for above incidents were followed appropriately.

No deficiencies cited during today's visit. An exit interview was conducted with Andrea Eldridge and a copy of this report was left with Andrea.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 04/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2022
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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