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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700997
Report Date: 03/30/2022
Date Signed: 03/30/2022 06:39:08 PM

Unsubstantiated


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
01/21/2022 and conducted by Evaluator Maja Jensen
COMPLAINT CONTROL NUMBER: 27-AS-20220121155252
FACILITY NAME:CAMLU ASSISTED LIVINGFACILITY NUMBER:
392700997
ADMINISTRATOR:WHITTED, ALMAFACILITY TYPE:
740
ADDRESS:6037 N. PERSHING AVENUETELEPHONE:
(916) 759-1969
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY:160CENSUS: 50DATE:
03/30/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Alma WhittedTIME COMPLETED:
07:00 PM
ALLEGATION(S):
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9
Questionable death
Residents are not properly assisted with incontinence care
Facility is not following residents' hospice care plans
Facility is malodorous
INVESTIGATION FINDINGS:
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On 3-30-22 at 10:00am Licensing Program Analysts (LPAs) Maja Jensen and Michael Bilger arrived at facility unannounced to continue a complaint investigation and deliver complaint findings for the allegations noted above. LPAs were allowed access to the facility and screened at the front door for COVID symptoms. LPAs Jensen and Bilger met with Administrator Alma Whitted and Resident Care Coordinator and informed of the purpose of today's visit.

LPAs reviewed resident files which included a physician report, needs and service plans, admission agreements, various special incident reports and home health agency narratives. LPAs also reviewed records for hourly check logs, care logs, death reports, police department incident reports, American Medical Response reports and 911 call logs. In addition LPAs conducted interviews with residents, staff and hospice workers.

The Investigations Bureau (IB) conducted an investigation in to allegation 1. Questionable Death
continued.........
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022
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 5
Control Number 27-AS-20220121155252
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: 03/30/2022
NARRATIVE
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Based on records reviewed by the IB, the preponderance of evidenced standard is not met, therefore this allegation is UNSUBSTANTIATED.

Allegation 2. Residents are not properly assisted with incontinence care, was found to be unsubstantiated based on record reviews and interviews with staff and residents. LPAs interviewed staff1 (S1), S2, S3, S4. LPAs also interviewed resident1 (R1), R2. Additionally, LPA interviewed two hospice staff members who manages a total of 6 hospice residents in care at facility. LPA also reviewed care logs for incontinence care. Care logs indicate incontence care is consistently performed for residents in care. Interviews conducted did not reveal a lack of incontinence care performed. Based on interviews conducted and records reviewed the preponderance of evidenced standard is not met, therefore this allegation is UNSUBSTANTIATED.

Allegation 3. Facility is not following residents' hospice care plans, was found to be unsubstantiated based on interviews conducted with Hospice Case Managers. Based on interviews conducted and records reviewed the preponderance of evidence standard is not met, therefore this allegation is UNSUBSTANTIATED.

Allegation 4. Facility is malodorous, was found to be unsubstantiated. LPA Maja Jensen visited the facility on three separate occasions to conduct complaint investigations and was not able to detect an unusual odor. The allegation is also unsubstantiated based on interviews conducted with residents. Based on interviews conducted and a physical sensory assessment of the facility the preponderance of evidence standard is not met, therefore this allegation is UNSUBSTANTIATED.

An exit interview was conducted and a copy of this report was given to the facility.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
01/21/2022 and conducted by Evaluator Maja Jensen
COMPLAINT CONTROL NUMBER: 27-AS-20220121155252

FACILITY NAME:CAMLU ASSISTED LIVINGFACILITY NUMBER:
392700997
ADMINISTRATOR:WHITTED, ALMAFACILITY TYPE:
740
ADDRESS:6037 N. PERSHING AVENUETELEPHONE:
(916) 759-1969
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY:160CENSUS: 50DATE:
03/30/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Alma WhittedTIME COMPLETED:
07:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Positive COVID-19/symptomatic staff are required to work at the facility
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 3-30-22 at 10:00am Licensing Program Analysts (LPAs) Maja Jensen and Michael Bilger arrived at facility unannounced to continue a complaint investigation. LPAs were allowed access to the facility and screened at the front door for COVID symptoms. LPAs Jensen and Bilger met with Administrator Alma Whitted and Resident Care Coordinator Andrea Eldridge and informed of the purpose of today's visit.

Continued....
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20220121155252
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: 03/30/2022
NARRATIVE
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2
3
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This allegation NEEDS FURTHER INVESTIGATION. This report is replaced by 9099 dated 4/15/22
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20220121155252
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: 03/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
CCR
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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: 03/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5