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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700997
Report Date: 12/04/2023
Date Signed: 12/04/2023 03:07:38 PM


Document Has Been Signed on 12/04/2023 03:07 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
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:
12/04/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:22 AM
MET WITH:Gretchen MonaresTIME COMPLETED:
03:30 PM
NARRATIVE
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LPA Johnson arrived unannounced to follow-up on the 30 day notices submitted to two residents for various infractions.

During the investigation the department was able to determine that there were several incidents that should have been reported to the department as well as other local authorities. The department discovered that the facility did not report incidents detailed in the notices that were given to R1 and R3 to support the decisions to have these residents move out.

On or about 10/01/22, R1 was in a physical alter with another resident; staff S1 witnessed R1 "smack and scratch R2 after R2 turned out the lights in the resident lounge." Police were not called, no SOC 341 (REPORT OF SUSPECTED DEPENDENT ADULT/ELDER ABUSE) submitted or an incident report to the department.

Again on 5/30/23 R1 rammed his wheelchair into R2 and assaulted R2 by punching him in the shoulder. R1 continued with a letter threatening to "beat R2 within inches of life." Police were not called, no SOC 341 submitted or an incident report to the department.

Additionally, on or about 3/23/23, R3 was in a verbal and physical altercation with R4; two staff witnessed R3 pull the walker of R4 and then kicked R4. The documentation does not say where R4 was kicked. Police were not called, no SOC 341 submitted or an incident report to the department.

The department has determined that the facility did not report incidents that are being identified as reasons along with other alleged incidents to deliver 30 day notices to R1 and R3. Based on the findings the facility did not report as mandated reporter incident of assaults on more than one occasion.



SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 12/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/04/2023
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 12/04/2023 03:07 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
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: 12/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/05/2023
Section Cited
CCR
87211(a)(1)

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Reporting Requirements
Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: 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; and disposition of the case.
This requirement is not met as evidenced by:
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Licensee will have an outside agency conduct a training for Mandated reporting requirements for all staff and managers. The training schedule will be submitted to the department by the close of business
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Based on interviews and records review, the licensee did not submit a written incident report to Licensing as required. Resident Care Director confirmed with LPA that an incident report was not submitted for any of the identified incidents in the report for today's visit. This poses an immediate health, safety, or personal rights risk to residents in care.
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on 12/5/2023. The facility will submit the list of individuals trained or the sign in sheet for the training by the plan of correction date. The facility will be responsible for finding a vendor that will conduct the training from a list of providers on the CDSS website.

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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 RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 12/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/04/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2