392700997-2-25-2022-27-AS-LKIG-CDPW5S-20220421165933

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392700997
Report Date: 02/25/2022
Date Signed: 02/25/2022 05:58:06 PM

Substantiated

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
02/22/2022 and conducted by Evaluator Maja Jensen

COMPLAINT CONTROL NUMBER: 27-AS-20220222163759

FACILITY NAME:	CAMLU ASSISTED LIVING		FACILITY NUMBER:	392700997
ADMINISTRATOR:	WHITTED, ALMA		FACILITY TYPE:	740
ADDRESS:	6037 N. PERSHING AVENUE		TELEPHONE:	(209) 951-2030
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95207
CAPACITY:	160	CENSUS: 57	DATE:	02/25/2022
		UNANNOUNCED	TIME BEGAN:	09:38 AM
MET WITH:	Alma Whitted		TIME COMPLETED:	06:15 PM

ALLEGATION(S):

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Lack of care and supervision
Facility has bedbugs
buildings and grounds not safe and sanitary

INVESTIGATION FINDINGS:

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On 02/25/2022, Licensing Program Analysts (LPAs) Avelina Martinez and Maja Jensen conducted an unannounced complaint investigation regarding the above allegations. LPAs discussed the purpose of the visit with Administrator, Alma Whitted.

Throughout the investigation, LPA Jensen conducted interviews, toured the facility, and obtained facility records. During the Feburary 25, 2022 visit, LPA Jensen observed cigarette butts in non-designated smoking areas on the resident patio. LPA Jensen observed cigarettes in the flower bed, patio sidewalks and throughout the landscaping. In addition LPA Jensen observed a discarded surgical mask in the resident gazebo sitting area as well as miscellaneous trash including paper wrappers and plastic bag. The gazebo benches were unsanitary.

Continued...

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 02/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2022

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 4

Control Number 27-AS-20220222163759

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: 392700997
	VISIT DATE: 02/25/2022

NARRATIVE

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The exterior covered patio overhang was observed to have exposed wires adjacent to the emergency exit door. The resident patio sidewalk leading to the southside of the building was observed to have a garden hose laying across the path which creates a tripping hazard for residents. A broken electrical outlet was also observed on the path leading to the southside of the building. LPA Jensen observed the rear of the southside of the building has overgrown grass, a pile of dirt and debris and heavy machinery that is exposed and accessible to the residents. The roof of the southside of the building was observed to be missing a tile. LPA Jensen observed 5 window screens on the first level that were torn and not in good repair.

In the interior of the facility LPA Jensen observed the following:
Dining hall baseboards that had peeling paint, cracks and were seperating from the wall.
Two spiders near the cracked baseboards in the dining hall south corner.
Walls in the dining room with holes in the drywall
Uneven transition strip not in good repair by emergency exit door in the dining hall causing a tripping hazard
Several floor boards in the dining hall not in good repair
An electric outlet with a cover not installed properly
A camera on the ceiling between the dining hall and front desk with exposed wires
A ceiling tile by the activity room next to the stairs with water damage and mold
Resident 1's room was observed to have a fire alarm with exposed wires
Resident 1's room was observed to have a bent screen that was not in good repair

The Administrator confirmed the facility had at least two known cases of bed bugs which started February 18. The Administrator advised a pest service was called out to the facility on February 21 and the facility is waiting to receive the pest control report which has been delayed due to bereavement leave of pest control staff. Off duty personnel was observed entering the facility without a mask and without signing in or being screened.

Continued......

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 02/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 27-AS-20220222163759

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: 392700997
	VISIT DATE: 02/25/2022

NARRATIVE

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Moreover, during the complaint investigation visit, LPA Jensen shadowed facility staff 1 (S1) delivering tray service at lunch. At 12:06pm lunch was delivered in room to resident 3 (R3), at 12:07 lunch was delivered in room to resident 4 (R4) and S1 called another staff member (S2) to feed R4, S2 arrived within 4 minutes minutes. At 12:12pm lunch was delivered in room to resident 5 (R5), at 12:16pm lunch was delivered in room to resident 6 (R6). When lunch was delivered to R6, R6 complained of pain and S1 called staff 3 (S3) on the radio to respond. S3 did not arrive to the room of R6 until 12:44pm and at that time R6 received pain medication. As a result of S3 being occupied with other residents, R6 had to wait 28 minutes for pain medication.

As a result of this visit, the following deficiencies were cited, per Title 22 Regulations. The deficiencies were cited on 9099-D.

Immediate civil penalty of $500 for not ensuring the personal rights of persons in care to safe and healthful accommodations is being issued on February 25, 2022.

REPEAT VIOLATIONS

1. Violation of California Code of Regulations Section 87303(a). A previous licensing report was issued on 1/24/22 giving notice of the same violation. A $1000 civil penalty was issued on today's visit of 2/25/22.

An exit interview was conducted and a copy of this report was given with appeal rights.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja Jensen	TELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 02/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 27-AS-20220222163759

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: 392700997
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/25/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/31/2022 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	873039a) Maintenance and Operation 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.	1 2 3 4 5 6 7	Administrator agrees complete all repairs by 3/31/22.
	8 9 10 11 12 13 14	This requirement was not met based on observation of LPA observing the building and grounds to be unsanitary and not in good repair. This poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
Type A 03/04/2022 Section Cited HSC 1569.50(a)(3)	1 2 3 4 5 6 7	Health and Safety Code 1569.50(a)(3) Conduct Inimical: Conduct which is inimical to health, morals, welfare or safety of either an individual in, or receiving services from the facility or the people of the State of California. This requirement was not met as evidenced by	1 2 3 4 5 6 7	The Administrator agrees to conduct a donning and doffing training for all staff and conduct a training for front desk staff on pre-screening of residents by 3/4/22.
	8 9 10 11 12 13 14	based on observation the facility did not follow proper usage of face covering and did not implement COVID-19 pre-screening measures at entrance of facility. This poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14

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: Maja Jensen	TELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:	DATE: 02/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2022

LIC9099 (FAS) - (06/04)

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