392700997-10-15-2021-27-AS-ABOE-C7U3BP-20211015180639

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392700997
Report Date: 10/15/2021
Date Signed: 10/15/2021 06:06:47 PM

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 LIVING		FACILITY NUMBER:	392700997
ADMINISTRATOR:	WHITTED, ALMA		FACILITY TYPE:	740
ADDRESS:	6037 N. PERSHING AVENUE		TELEPHONE:	(209) 951-2030
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95207
CAPACITY:	160	CENSUS: 56	DATE:	10/15/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	01:10 PM
MET WITH:	Alma Whitted		TIME COMPLETED:	06:20 PM

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On 10/15/2021 at 1:10pm, Licensing Program Analyst (LPA) Ashley Boothe, arrived unannounced to conduct a conduct a Prelicensing Inspection for a Change of Ownership Application. LPA met with Administrator and explained the purpose of today’s inspection. Administrator, applicant on site, and current licensee gave verbal designation for Designee Staff one (S1) to accompany LPA during today's inspection. Current Census is 56 of which 6 are hospice. LPA observed resident roster last updated on 8/22/2021. LPA observed Administrator Certificate expires on 10/10/2021. 4 of 4 staff observed with criminal record clearance associated in the Licensing Information System (LIS).

LPA and S1 toured the facility inside and outside to ensure the safety of the residents, interacted with a random number of residents during this visit and observed residents engaged in dining and games in communal living room. Observed resident rooms, restrooms, medications room, dining room, communal areas, patio, kitchen, and staff offices. The temperature inside the facility was measured at 76*F which is within the required range of 68*F and 85*F, or in areas of extreme heat the maximum shall be 30 *F less than the outside temperature. Observed air conditioning system not in working order and plan in place all residents have access to individual air conditioning units to be maintained in working order at all times. The heater repaired on 10/14/2021 faulty switch replaced found to be in working order. The hot water was measured between 110*F and 113 *F which is not less than 105*F and not more than 120 *F. Resident's Personal Rights, Resident Counsel, and Let Us Know posting in main area accessible to all residents, family, visitors, and staff. Observed fire extinguisher last inspected on 8/15/2021, pull alarm system. Fire sprinkler system last inspected on 9/2/2021.

Continued on 809.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 10/15/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2021

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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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
	VISIT DATE: 10/15/2021

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Continued from 809.

Observed food supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days which shall be maintained on the premises at all times. Kitchen staff two (S2) is current with serve safe certification. Hand washing sink with soap, paper towels, hand washing sign, and covered trash can. Hot water signs posted to notify of water above regulatory range. Refrigerator and freezer temperatures were within adequate range per regulations. Observed knives inaccessible to residents.

Observed dining room with tables and chair setup for social distancing and communal meals and small group activities.

Observed south corridor second floor inaccessible to residents with stripped dry wall and flooring. Administrator stated second floor repair work completion is expected 60 days. Observed two of two storage rooms unlocked and accessible to residents housing paint and construction supplies. Observed residents rooms under construction with signs posted "do not enter" but door handles removed, not in good repair with exposed wires and piping. Observed ceiling tiles missing on first floor south corridor and north corridor damaged wall from water fountain removal. Observed carbon monoxide detectors not in working order or removed. Observed two window screens off window on first floor. Observed outside a pile of loose bricks, fallen tree branch, and shed not in good repair on the facility property.

Observed call system in working order but Staff three(S3) stated they did not have a phone or access to a phone since starting two and a half months ago. Staff four (S4) phone in working order. Observed staff did not respond to two calls to second floor rooms and S3 responded to S1 on the walkie talkie 7 minutes after pull cord was activated. Observed no chairlifts in the three stairwells and S1 stated unaware if any were on site. Observed resident room 106 to use oxygen and no signs posted to demark.

Observed the centrally stored medications area to be locked and inaccessible to residents. Observed medications room, three of three medications counted matched MAR's and Centrally Stored Log. Observed PRN documented. Observed Resident one (R1) with bedrails and no physician's order filed. One of three resident files reviewed with no current admissions agreement on file for the facility.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 10/15/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2021

LIC809 (FAS) - (06/04)

Page: 4 of 4

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
	VISIT DATE: 10/15/2021

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Continued from 809 C.

The following are required before facility can be approved for licensure:

1. Repair or replace carbon monoxide detectors are in working order.

2. Repair or replace window screens
3. Repair or replace ceiling tiles, dry wall from water fountain, and rooms not in good repair
4. Repair, replace, or remove pile of loose bricks, fallen tree branch, and shed not in good repair
5. Ensure all hazardous items stored or areas are made inaccessible to residents
6 Ensure all staff have access and training to use of the call system to provide care and supervision
7. Ensure all residents with bedrails have documented physician's order.
8. Ensure all rooms are demarked for Oxygen usage when in use
9. Ensure all stairwells chair lifts are maintained at all times
10. Update Resident roster
11. Ensure all resident and staff files are complete and up to date.

LPA requests Applicant notify when the above requirements have been met and the facility is ready for re-evaluation for licensure. At this time the facility is not approved to be licensed. A follow up report documenting corrections will be created once corrections are received and application approved.

Per the California Code of Regulations, Title 22, no deficiencies cited. Exit interview held, copy of report given.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 10/15/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2021

LIC809 (FAS) - (06/04)

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