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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700997
Report Date: 12/02/2022
Date Signed: 12/06/2022 09:04:43 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 12/06/2022 09:04 AM - 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:DIANE WRIGHTFACILITY TYPE:
740
ADDRESS:6037 N. PERSHING AVENUETELEPHONE:
(209) 951-2030
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY:160CENSUS: 48DATE:
12/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Diane WrightTIME COMPLETED:
02:00 PM
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On 12/2/22 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a one year annual inspection. LPA Jensen met with Executive Director Diane Wright and explained the purpose of today's visit.

The facility is a two story building with a single designated entrance. There are infection control and COVID screening signs posted at the entrance and throughout the building. At the front hall reception desk there is an electronic sign in and screening system that generates a visitor tag. All staff were observed to be wearing masks. The facility maintains an adequate supply of PPE.

The facility was observed to be sanitary and free of odor. LPA Jensen toured the kitchen, the dining hall, 2 activity rooms, the laundry rooms, main hall bathrooms, guest suites, medication room and grounds. The grounds were observed to be well maintained and all paths were free of obstruction. The window screens were all observed to be in good repair. The fire extinguishers were last serviced in September of 2022 and are in compliance.

The kitchen was observed to be sanitary. There was a menu posted and lunch service was observed. The lunch served was consistent with the menu that was posted. The kitchen is separated from the dining hall and only employees have access to the kitchen. First aid kits were maintained and observed to be complete. Toxins and cleaning supplies were observed to be stored away from all food products. The ice machine was observed to be sanitary. LPA Jensen observed in excess of a 7 day supply of non-perishable food and a 2 day supply of non-perishable food.

LPA Jensen toured 4 resident suites. The suites were observed to be adequately furnished and lit. 2 of 4 resident suites observed had portable heater units. 2 of 4 suites observed had an air conditioning unit in the window that was not properly sealed allowing for air flow from outside.
Continued on LIC 809C....
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 12/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2022
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: 12/02/2022
NARRATIVE
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The portable heaters do not have a mechanism to set the unit to specific temperature. LPA Jensen interviewed resident 1 (R1) and resident 2 (R2) with portable heaters in their room and R1 and R2 both indicated they have to constantly turn the heaters on and off in an attempt to adjust the temperature. 1 of 4 resident rooms had an HVAC system that had a broken fan creating a constant noise. LPA Jensen tested the call alert system in the room of R1 at 11:14am, LPA Jensen waited 20 minutes and there was no response by staff. LPA Jensen tested the call alert system in the room R3 at 10:34, LPA Jensen waited 12 minutes and there was no response by staff. Water temperature in resident suites was measured at 116 degrees which falls within the required regulatory range of 105-120 degrees.

LPA Jensen observed the medication room to be organized and observed medications to be locked in med carts. The narcotics were locked separately. LPA Jensen conducted an audit of the narcotics in collaboration with Staff 1 (S1) and found the documentation and medication count to be in order.

LPA Jensen observed an extensive activities program to be offered including but not limited to Holiday shopping, holiday dress up days, Christmas caroling, spiritual services, gift exchanges, shopping excursions, resident socials and service animal visitation dates.

LPA Jensen reviewed 3 resident files and 2 staff files. The facility is in the process of conducting file audits and reorganizing staff and resident files to stream line and ensure all necessary documentation is easily accessible.

Deficiencies are being cited from the California Code of Regulations (CCR) Title 22, Division 6. Failure to correct deficiencies may result result in civil penalties.

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

DATE: 12/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 12/06/2022 09:04 AM - 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: 12/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/09/2022
Section Cited

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87303 Maintenance and Operation
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(b) A comfortable temperature for residents shall be maintained at all times.

(1) The facility shall heat rooms that residents occupy to a minimum of 68 degree F, (20 degrees C). This requirement was not met as evidenced by:
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Based on an interview with the Executive Director there are currently 9 occupied units using portable heaters which does not allow for accurately setting a temperature in resident suites within the required range and creates a tripping and fire hazrd. This poses a potential risk to the health saftey and personal rights of residents in care.
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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: 12/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 12/06/2022 09:04 AM - 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: 12/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/03/2022
Section Cited

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(i) Facilities shall have signal systems which shall meet the following criteria:

(1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall:

(A) Operate from each resident's living unit.

(B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff.
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This requirement was not met as evidenced by:
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Based on LPA Jensen's test of 2 resident suite signal systems for which there was no response by staff in over ten minutes each. This poses an immediate health, safety and personal rights risk to residents in care.
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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: 12/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4