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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700997
Report Date: 11/13/2023
Date Signed: 11/14/2023 09:35:36 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 11/14/2023 09:35 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:JENNIFER WHITELYFACILITY TYPE:
740
ADDRESS:6037 N. PERSHING AVENUETELEPHONE:
(209) 951-2030
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY:160CENSUS: 45DATE:
11/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:47 AM
MET WITH:Gretchen Monares(LVN)TIME COMPLETED:
04:08 PM
NARRATIVE
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Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an annual inspection. LPA met with G Monares (LVN) and explained the purpose of the visit. Later joined by Zach Butcher. There was no current certified RCFE Administrator during this inspection.

LPA inspected the physical plant with G. Monares including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 117 degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees. The bus used to transport residents does not have the required license number which is required identifying information.(Advisory given). Also observed was the elevator is out of compliance with work that is needed to get permit to operate.(Advisory given).

Fire extinguishers and smoke detectors/carbon monoxide detectors are operational. LPA observed centrally stored medications are kept locked and inaccessible to residents. LPA reviewed and compared resident medication vs. resident medication logs. During the medication review LPA and LVN observed that R1 and R2 had missed doses of medications on multiple days. LPA reviewed 15 resident and 5 staff files, including criminal record clearances. During the staff file review LPA observed a missing health screening for S1. All staff are fingerprinted and cleared. First aid kit was checked and is complete.

Deficiencies were cited pursuant to Title 22 rules and regulations, Health and Safety Codes. Exit interview conducted
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 11/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/13/2023
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 11/14/2023 09:35 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: CAMLU ASSISTED LIVING
FACILITY NUMBER: 392700997

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/14/2023
Section Cited
CCR
87405(a)

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87405(a) All Facilities shall have a qualified and currently certified administrator. This requirement was not met as evidenced by interviews with staff.
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Licensee will submit to LPA an updated LIC500 and LIC200 with an employee who has a current administrator certificate and who will act in the administrator capacity until Licensee finds and updates the Administrator positions. Licensee will send to LPA by end of day on 11/14/2023
Type A
11/14/2023
Section Cited
CCR
87465(c)(2)

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87465(c)(2) Incidental Medical and Dental Care. Once ordered by the physician the medication is given according to the physician's directions.
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The Administrator will developed a plan on how the facility will follow the Physician's orders and document correctly when medications are missed. Please send the agenda along with the sign-in sheet for the in-service, by POC date or give a time when the training will take place and send that information to the department
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This requirement is not met as evidenced by: Based on observation and records review, the Licensee did not ensure medications ordered for residents were given as prescribed which poses an immediate health and safety risk to residents in care.
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The facility will also report all incidents of medication errors, missed medication Etc.. to the resident's Primary Care Physician and to the department.
Type B
11/17/2023
Section Cited
CCR
87411(f)

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General. Good physical health of personnel shall be verified by a health screening, including a T.B. test, performed and signed by a physician not more than six months prior to or seven days after employment. LPA observed staff did not have a health screening and TB test results in S1's file.
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Administrator to provide a health screening/TB results for staff (S1) by POC date 11/17/2023
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 RiosTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 11/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/13/2023
LIC809 (FAS) - (06/04)
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