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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700997
Report Date: 08/03/2023
Date Signed: 08/03/2023 01:02:02 PM


Document Has Been Signed on 08/03/2023 01:02 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: DATE:
08/03/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Gia CocolaTIME COMPLETED:
12:15 PM
NARRATIVE
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On 8/3/23 at approximately 10:15am Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a case management related to an incident report for Resident 1 (R1). LPA Jensen met with Executive Director Gia Cocola and explained the purpose of today's visit.

LPA Jensen reviewed 3 incident reports for R1. On 7/10/23, 7/15/23 and 7/17/23 R1 went to the emergency room for elevated blood sugar levels.

LPA Jensen reviewed the LIC 602 which states that the resident is not able to administer his own medication or monitor his own glucose. LPA Jensen reviewed R1's need and service plan and it indicates that a licensed Practical/Vocational nurse will assist resident with glucose monitoring and insulin.

LPA Jensen interviewed R1 who stated no one monitors his glucose and he administers his own insulin. LPA Jensen interviewed staff 1 (S1) and staff 2 (S2) and both confirmed that the resident administers his own insulin and is responsible for monitoring his own glucose.

A deficiency is 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.

The Executive Director stated the facility has an LVN on staff that has agreed to take over medication management for R1 effective immediately.

An exit interview was conducted and a copy of this report, the LIC 811 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: 08/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2023
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 2


Document Has Been Signed on 08/03/2023 01:02 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: 08/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/04/2023
Section Cited
CCR
87628(a)

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Diabetes
The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by an appropriately skilled professional. This requirement was not met as evidenced by:
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The Licensee agrees to have an appropriately skilled professional administer medication and conduct glucose monitoring for any resident that is unable to manage their own medication as specified on the LIC 602 effective immediately. No further plan of correction is required at this time.
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Based on LPA Jensen's record review of the LIC 602, LIC 624's and needs and service plan as well as LPA Jensen's interviews with 2 staff members and 1 resident, the resident has not had medication administered by a skilled professional. This poses an immediate 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: 08/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2