392700997-1-19-2024-27-AS-LRIS-D45USA-20240408155000

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392700997
Report Date: 01/19/2024
Date Signed: 01/19/2024 01:06:41 PM

Unsubstantiated

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
01/17/2024 and conducted by Evaluator Albert Johnson

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20240117162829

FACILITY NAME:	CAMLU ASSISTED LIVING		FACILITY NUMBER:	392700997
ADMINISTRATOR:	JENNIFER WHITELY		FACILITY TYPE:	740
ADDRESS:	6037 N. PERSHING AVENUE		TELEPHONE:	(209) 951-2030
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95207
CAPACITY:	160	CENSUS: 45	DATE:	01/19/2024
		UNANNOUNCED	TIME BEGAN:	10:47 AM
MET WITH:	Nellie Gomez		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Licensee evicted resident without sufficient cause.

INVESTIGATION FINDINGS:

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On 1/19/24 at approximately 10:40am Licensing Program Analyst (LPA) Albert Johnson arrived at facility unannounced to investigate the above listed allegation. LPA Johnson met with Business Office Manager Nelle Gomez and explained the purpose of today's visit. LPA was later contacted by Gretchen Monares via phone.

Based on records reviewed LPA was able to determine that 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.

Unsubstantiated

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Albert Johnson	TELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20240117162829

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: 01/19/2024

NARRATIVE

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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.

R1 denied that the incidents occurred as reported, but, confirms that the incident described in this report, he feels that he was the victim and he was defending himself.

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.

The facility was given a citation on 12/4/23 for not reporting the incidents. Therefore, no citations will be given for not reporting these incidents.

The facility did submit the 30 day notice to the department and the notice was a legal notice that contain the required information including resources for alternative housing and assistance.

Based on records reviewed and the review of the resident's 30 day notice, 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.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, no deficiencies are being cited. Exit interview held, a copy of report given.

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Albert Johnson	TELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2024

LIC9099 (FAS) - (06/04)

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