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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700997
Report Date: 06/07/2024
Date Signed: 06/10/2024 10:08:20 AM

Document Has Been Signed on 06/10/2024 10:08 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:CAMLU ASSISTED LIVINGFACILITY NUMBER:
392700997
ADMINISTRATOR/
DIRECTOR:		CHANTLLE HUDSONFACILITY TYPE:
740
ADDRESS:6037 N. PERSHING AVENUETELEPHONE:
(209) 951-2030
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY: 160CENSUS: 48DATE:
06/07/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Ignacio Lopez IIITIME VISIT/
INSPECTION COMPLETED:
03:01 PM
NARRATIVE
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On 4/25/2024, LPA Albert Johnson made an unannounced visit on this date to conduct a health and safety check along with follow-up on incident reports. LPA met with Administrator Ignacio Lopez III

The temperature in the facility was a comfortable 77 degrees in the main area. There was constructions happening through out the facility. The facility had issue with six rooms which involved air conditioning. The facility has addressed these issue and is working toward replacing units and upgrading the HVAC system. The fixed system in the kitchen is out of compliance and needs servicing. The last service date was 7/18/2023 this requires a semi-annual servicing. Citation and civil penalty assessed.

As a reminder the facility must during construction ensure that during all phases of alteration to the facility, maintain the facility in compliance with Title 22 regulations. The licensee must protect the clients in care from any health and safety hazards during and/or resulting from construction.

Health and Safety check today included overall safety of the facility including food supply, physical plant and staffing. The facility will continue to monitor the construction areas to maintain the safety of all residents including visitors during the 2nd phase of the construction project. (Advisory given).
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 06/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/07/2024
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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Document Has Been Signed on 06/10/2024 10:08 AM - It Cannot Be Edited


Created By: Albert Johnson On 06/07/2024 at 02:29 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: CAMLU ASSISTED LIVING
FACILITY NUMBER: 392700997

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
06/08/2024
Section Cited

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87203 Fire Safety. All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met based on: Observation, The facility failed to maintained in conformity with the regulations
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adopted by the State Fire Marshal. The "Fixed System" or "Ansul System" in the kitchen, this system is scheduled for a semi-annual maintenance and was last serviced on 7/19/2023
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as proof and submit Statement of Compliance by POC date.

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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:Lisa Rios
LICENSING EVALUATOR NAME:Albert Johnson
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2024


LIC809 (FAS) - (06/04)
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