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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700997
Report Date: 04/26/2024
Date Signed: 04/26/2024 04:30:28 PM


Document Has Been Signed on 04/26/2024 04:30 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:
04/26/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Ignacio TIME COMPLETED:
04:45 PM
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On 4/26/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a case management regarding an incident occurring on 2/16/23. LPA Jensen met with Executive Director Ignacio Lopez III and explained the purpose of today's visit.

The incident was self reported. The facility reported that Resident 1 (R1) entered Resident 2's (R2) room and made unwelcome sexual advances upon R2. The incident was reported to all required entities. The police report was obtained from Stockton Police Department. R1 was interviewed and confirms he visited R2's apartment briefly to give her some sweets where he remained at the door and then left. R1 denied all sexually assaulting R2, and no visible injuries noted in the report. The Executive Director (ED)was interviewed and advised there has never been any issues or prior history involving R1 and R2. The ED confirms there has been one previous incident with R1 exposing himself; however, he was made aware that behavior was not allowed, and it was unclear if the exposure was on purpose or accidental. There is no mention of any sexualized behavior in the Needs and Services Plan for R1. Facility staff implemented a safety plan for R2, where she is to be escorted to and from her apartment and ensuring her front door is locked when she is home. R2 stated she felt safe residing at the facility and with staff caring for her. R1 was advised by law enforcement officers to no longer interact with R2 nor be near R2. Based on interviews conducted with staff present at the time of this incident, the safety plan implemented for R2 was verbal and cross reported shift to shift with no definitive terms or time frame documented. Technical assistance is being provided with a recommendation to document any such safety plan or directives given to staff to ensure the safety of residents in care.

The physician's report for R1 is dated 8/15/22 and states there is no indication of inappropriate behavior. Based on the incident of 2/16/23 and a prior incident with R1 exposing himself the Department is requesting a new LIC 602 be obtained in order to determine if there any unidentified service needs and ensure R1 is compatible with this facility's population and level of care.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2024
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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: CAMLU ASSISTED LIVING
FACILITY NUMBER: 392700997
VISIT DATE: 04/26/2024
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For the purposes of this case management interviews were conducted and the following documentation was reviewed:

Stockton Police Report
Facility Incident Report
Resident file for R1
Resident file for R2

An exit interview was conducted and a copy of this report and appeal rights were provided.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2024
LIC809 (FAS) - (06/04)
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