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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700997
Report Date: 06/22/2023
Date Signed: 06/22/2023 04:20:52 PM


Document Has Been Signed on 06/22/2023 04:20 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:JENNIFER WHITELYFACILITY TYPE:
740
ADDRESS:6037 N. PERSHING AVENUETELEPHONE:
(209) 951-2030
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY:160CENSUS: 57DATE:
06/22/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Gia Cocola
TIME COMPLETED:
04:30 PM
NARRATIVE
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On 6/22/23 at 2:30pm Licensing Program Analysts (LPAs) Maja Jensen and Jennifer Fain arrived at facility unannounced to conduct a case management for deficiencies in relation to incident reports received by the Department on 6/5/23. LPAs met with Executive Director Gia Cocola and explained the purpose of today's visit.

Reporting Requirements
On 6/5/23 six incident reports were faxed to the Regional Office for separate incidents that occurred on 5/3/23, 5/4/23, 5/14/23, 5/17/23, 5/22/23 and 5/25/23.

Document Request
On 6/5/23 Licensing Program Analyst Maja Jensen requested documents a due date of 6/8/23. An extension was granted through 6/12/23 and a further extension was granted through 6/13/23 and again through 6/14/23. LPA Jensen informed Executive Director Gia Cocola that only partial documents were received. Executive Director Gia Cocola showed LPA Jensen an email that was sent on 6/14/23 at 12:44pm. There were 4 consecutive emails that were sent back to back. LPA Jensen received 2 of 4 emails.

During the course of the interview with Executive Director Gia Cocola, LPA Jensen was advised there was a short delay in sending the requested documentation as she needed to verify what documents could be released versus what documents are internal, as such technical assistance was provided related to the Inspection Authority of the Licensing Agency.

Continued on LIC 809C...
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


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: 06/22/2023
NARRATIVE
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Continued from LIC 809

LPA Jensen requested and received the following resident records for R1:
Admission Agreement
Physician's report
Pre-placement appraisal
needs and service plan
Emergency ID and contact information
Charting Notes
All incident Reports

Deficiencies are being cited from the California Code of Regulations, Title 22, Division 6.

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

DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 06/22/2023 04:20 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: 06/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/29/2023
Section Cited
CCR
87211(a)(1)(D)

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Reporting Requirements
A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below...
Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement was not met as evidenced by:
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The Licensee has implemented a new protocol for incident reporting wherein the Executive Director is immediately notified of the occurrence and an incident report is written up within 24 hours for review by upper management and their consulting group. No further plan of correction is required at this time.
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Based on the Department's receipt of 6 incident reports that were sent more than 7 days after occurrence. This poses a potential risk to the health, safety 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: 06/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2023
LIC809 (FAS) - (06/04)
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