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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 04:19:56 PM


Document Has Been Signed on 04/15/2022 04:19 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:Post LicensingUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Andrea EldridgeTIME COMPLETED:
03:00 PM
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On 4/14/22 Licensing Program Analysts (LPAs) Maja Jensen and Michael Bilger arrived unannounced to conduct a post licensing inspection. The facility is a two story building with one central entrance. LPAs were allowed access to the facility and were temperature screened and COVID symptom screened. COVID signage was observed to be posted in the facility.

LPAs Jensen and Bilger toured the physical plant and the grounds including the kitchen, dining hall, activity room, common bathrooms and resident rooms. The facility was found to be clean and sanitary and contained adequate lighting and furniture for the comfort of the residents. The temperature in the facility was observed to be set at 72 degrees which is in the required range of between 68 degrees and 85 degrees. The facility has two stairwells and both are equipped with emergency evacuation chairs. Water temperature in the bathroom was measured at 116 degrees which is within the required range of 105 degrees and 120 degrees. The refrigerator was set at 36 degrees and the freezer was set at 10 degrees. LPAs observed an adequate emergency supply of water and food. LPAs observed the facility to have in excess of 2 days of perishable food and in excess of 7 days of non-perishable food. LPAs observed and reviewed ServSafe certifications for kitchen staff and a complete MSDS manual. The fire extinguishers were last serviced on August 16th, 2021 and are in compliance.

LPAs observed that there are renovations currently in progress at the facility. LPAs interviewed staff 1 who advised that there are 16 residents on the second floor. LPAs observed a storage room on the second floor directly across from the elevator that was unlocked and contained multiple toxins accessible to the residents. In addition, there is a sliding door on the second floor that allows access to the roof. The sliding door was observed to be open with only a screen that was shut but not locked leaving the roof accessible to residents. The roof has an uneven surface and poses a safety threat with tripping hazards to residents.

Staff files were reviewed for staff 2 (S2), staff 3 (S3) and staff 4 (S4). The first aid/CPR certificate for S2 was observed to be expired as of 12/12/21.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
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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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: 392700997
VISIT DATE: 04/15/2022
NARRATIVE
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There were deficiencies found and cited from the California Code of Regulations (CCRs) - Title 22.
An exit interview was conducted and a copy of this report was given to the Resident Care Coordinator Andrea Eldridge.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
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
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 04/15/2022 04:19 PM - It Cannot Be Edited

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: 392700997

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
874119(c)(1)
87411 Personnel Requirements - General
......
(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69

(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review of personnel file for S2 which contained a first aid/CPR certificate that had expired on 12/12/21, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/13/2022
Plan of Correction
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2
3
4
Licensee agrees to have any staff needing first aid/CPR training complete the necessary training and email proof of certification to LPA by May 13, 2022.
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 KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 04/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 04/15/2022 04:19 PM - It Cannot Be Edited

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: 392700997

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)(1)
87309 Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
(1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation of multiple toxins in an unlocked storage room next to the elevator on the second floor, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/19/2022
Plan of Correction
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Licensee agrees to replace the storage room door handle with a locking handle and keep the door locked when the room is unoccupied. Licensee will send photos of the locking door handle by email to the LPA by 4/19/22
Type A
Section Cited
CCR
87303(a)
87303 Maintenance and Operation

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
This requirement is not met as evidenced by:
Based on LPAs observation of an unlocked sliding door on the second level with access to a portion of the roof that was unstable with a high fall risk and tripping hazards, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/19/2022
Plan of Correction
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Licensee agrees to submit a plan to secure the access to the roof by email by 4/19/22.

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 KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 04/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4