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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700997
Report Date: 04/25/2024
Date Signed: 04/25/2024 12:32:54 PM


Document Has Been Signed on 04/25/2024 12:32 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:CHANTLLE HUDSONFACILITY TYPE:
740
ADDRESS:6037 N. PERSHING AVENUETELEPHONE:
(209) 951-2030
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY:160CENSUS: 46DATE:
04/25/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:G. Monares. and Ignacio LopezTIME COMPLETED:
12:45 PM
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On 4/25/2024, LPA Albert Johnson made an unannounced visit on this date to conduct a health and safety check along with follow-up on incident reports. LPA met with G. Monares and was introduced to the new Administrator Ignacio Lopez III

The temperature in the facility was a comfortable 74 degrees in the main area. There was constructions happening through out the facility. As a reminder the facility must during construction ensure that during all phases of alteration to the facility, maintain the facility in compliance with Title 22 regulations. The licensee must protect the clients in care from any health and safety hazards during and/or resulting from construction. LPA observed safety signs posted and areas controlled from access.

Health and Safety check today included overall safety of the facility including food supply, physical plant and staffing. The facility submitted an incident report for a medication error on 4/12/2024. The facility concluded it's own internal investigation and as a result of the medication error and investigation, S1 has been terminated and other Med-tech have received additional training in medication administration.

The facility has sent out several residents for falls. All resident have returned with the exception of R1.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2024
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


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
VISIT DATE: 04/25/2024
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R1 is currently at the San Joseph's Hospital and will be moving to an acute care for rehabilitation until R1 is able to return to the facility.

The facility has started an new Administrator/ Executive Director. The facility has not submitted the required information to appoint Ignacio Lopez III as the new Administrator. Licensee will submit to the department the required information to appoint the new Administrator including an updated LIC500 and LIC200. Licensee will send the requested information to LPA by end of day on 04/26/2024.

Today the facility was providing food service for upstairs residents in their rooms. Staffing for the day shift was adequate. No deficiencies were cited pursuant to Title 22 rules and regulations, Health and Safety Codes.

Exit interview conducted.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
LIC809 (FAS) - (06/04)
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