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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700997
Report Date: 04/06/2023
Date Signed: 04/06/2023 05:14:39 PM


Document Has Been Signed on 04/06/2023 05:14 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:DIANE WRIGHTFACILITY TYPE:
740
ADDRESS:6037 N. PERSHING AVENUETELEPHONE:
(209) 951-2030
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY:160CENSUS: 57DATE:
04/06/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Gia CocolaTIME COMPLETED:
05:15 PM
NARRATIVE
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On 4/6/23 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a case management related to the renovation project and HVAC replacement. LPA Jensen met with Executive Director Gia Cocola and explained the purpose of today's visit.

The HVAC replacement project plans approved by the Department had an original estimated completion date of February 2022. The completion date for the project was delayed due an unforeseeable supply chain issue. The Licensee submitted an updated time line for the project in February of 2023. LPA Jensen spoke to Licensee by telephone who advised that the project has again been delayed as a result of a permit issue with the City of Stockton. The project is now expected to be completed in 4-6 months time. The Licensee advised LPA Jensen that resident care will not be impacted through completion of the project and has agreed to send a revised timeline to LPA Jensen by 4/20/23.

In addition, it came to LPA Jensen's attention that there has been an change in Administrator. During the course of an interview with Executive Director, Gia Cocola, LPA Jensen was advised that the former Administrator exited her position approximately 3 weeks ago or around 3/9/23. The Executive Director also advised that she passed her Administrator's certification exam on 3/29/23 and is pending receipt of her certificate. LPA Jensen is requesting the following documentation by 4/13/23:

-A letter from the licensee and/or board appointing the individual as the Administrator
-An LIC 308
-Copy of current Administrator's certification
-Any documentation that meets the education and/or experience requirements
-An LIC 200 signed by the Licensee or designee
-An LIC 500 to indicate the days and hours the Administrator is in the facility
-An LIC 501 so we can determine if the Administrator meets the education/experience requirement
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 04/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2023
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: 04/06/2023
NARRATIVE
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Deficiencies are being cited from the California Code of Regulations (CCR) Title 22, Division 6. Failure to correct deficiencies may result in the assessment of civil penalties.

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

DATE: 04/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/06/2023 05:14 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: 04/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/13/2023
Section Cited

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Administrator Certification Requirements
All facilities shall have a qualified and currently certified administrator. This requirement was not met based on:
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Licensee agrees to submit the requested documentation for approval for a change in Administrator by Plan of Correction due date.
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The facility's former Administrator having exited the position on or around 3/9/23 and the facility not having any evidence of a new Administrator of record. This poses a potential 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: 04/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2023
LIC809 (FAS) - (06/04)
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