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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700997
Report Date: 02/01/2024
Date Signed: 02/23/2024 09:41:58 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/16/2023 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20231116110730
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:
02/01/2024
UNANNOUNCEDTIME BEGAN:
11:27 AM
MET WITH:G. MonaresTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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The heater does not work in some rooms
The facility is billing for additional services without notice or updating service plans
INVESTIGATION FINDINGS:
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On 2/1/24 at approximately 10:00am Licensing Program Analyst (LPA) Albert Johnson arrived at facility unannounced to investigate the above listed allegation. LPA Johnson met with Gretchen Monares and explained the purpose of today's visit.

Allegation: The heater does not work in some rooms. Based on records reviewed and touring the facility the allegation is substantiated. There are several room that are without proper working units those room are 31 rooms that are not working. The rooms are not being used any residents that were in those rooms have been moved

Continued
Substantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 27-AS-20231116110730
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 02/01/2024
NARRATIVE
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The facility provided a letter from 5/1/2023 identified as "2023 rate adjustments." This form was not signed by the residents or the responsible parties. The facility did not identify what number would constitute excessive use of tray service and failed to update the service plan to address the incur cost for tray service. R1 was billed for tray service on 4/23/23, this is the only record of this service and does not appear to be excessive.

R2 was billed for tray services on 12 occasions and 2 extra dinners from 12/18/2022 to 12/16/2023, totaling $300.00 dollars. The facility did not re-access R2 to determine if there was a change in service need. The facility was made aware by R2 that Staff/Waiter in the dining room continued to have conflict with him for an extended period of time. This is documented in the care notes for R2. The facility has recently terminated the Staff that was reportedly harassing R2.

The allegations are SUBSTANTIATED. A finding of substantiated means the preponderance of evidence standard has been met.

Deficiencies are being cited from the California Code of Regulations (CCR) and Health and Safety Code (HSC). Failure to correct deficiencies may result in the assessment of civil penalties.

An exit interview was conducted and a copy of this report and appeal rights were given.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20231116110730
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 02/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/15/2024
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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The facility will repair or replace the Unit for air-conditioning and heating by the POC date or provide the department with a plan to repair or replace the unit by 2/15/2024.
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This requirement is not met as evidenced by records reviewed the facility has 31 rooms without working heaters. This is a potential health and safety risk to residents in care.
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Type B
02/15/2024
Section Cited
CCR
87463(a)
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87463 Reappraisals (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to:
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The Administrator will update any and all service plans for any resident that is being billed for services not identified in their pre-appraisal or their current service plan. Proof of this will be submitted to licensing by 2/15/2024
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This requirement is not met as evidenced by records reviewed the facility did not address the additional use of tray services for R2 from 12/2022 through 12/2023.
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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: 02/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/16/2023 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20231116110730

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:
02/01/2024
UNANNOUNCEDTIME BEGAN:
11:27 AM
MET WITH:G. MonaresTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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The toilets do not work properly
INVESTIGATION FINDINGS:
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Based on review of maintenence records and interviews with residents the facility has not had problems with the plumbing that was out of the norm. The facility has had plumbing service as part of the ongoing service need. The facility denied having problems with water pressure, clogged toilets or any other plumbing issues. The facility has moved residents at their request when toilets or heating appears to be the problem. LPA was able to test the toilets and water pressure in multiple rooms. During the test LPA did not have any issues with toilets flushing and/or water pressure being low. The preponderance of evidence standards has not been met. The allegation is unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, the preponderance of evidence standards has not been met.
Unsubstantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4