392700997-12-16-2021-27-AS-MBIR-C9S2P2-20211216163336

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392700997
Report Date: 12/16/2021
Date Signed: 12/16/2021 04:33:40 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:	12/16/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	01:05 PM
MET WITH:	Alma Whitted		TIME COMPLETED:	04:33 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 12-16-21 at 1:05pm, Licensing Program Analyst (LPA) Michael Bilger conducted an unannounced pre-licensing visit to this facility. LPA met with Administrator Alma Whitted and explained the purpose of the visit. Brief interview was conducted with the Applicant who was contact by phone during visit. It was learned that this facility will be licensed as a Residential Care Facility for the Elderly (RCFE) to serve up to 160 residents. There were 56 residents present during today's pre-licensing visit, 8 residents are on hospice. Tour of the facility was conducted. Dining area, common areas, and all other areas intended for resident use were toured and observed to be furnished and maintained in compliance at this time. COVID Precautions in place including signage, PPE storage and 30-day supply. Isolation rooms designated. LPA observed no obstruction of emergency exits. Exit signs in place as appropriate. Fire extinguishers in place upstairs and downstairs and fully charged. Facility map indicating emergency exits posted in appropriate locations. Complaint poster and Ombudsman Poster observed. Kitchen area was toured. Food supply for 2-day perishable and 7-day non-perishable quantities were reviewed to make sure that this facility is in compliance at this time. Medication room, located on first flour, was toured. First aid kit was observed to be present and contained all required components at this time. Medication count for 3 of 3 residents was conducted which matched MARS and centrally stored logs. 3 of 3 resident bed rail orders verified. 4 of 4 staff charts were reviewed and complete. A tour of the resident bedrooms was conducted. Furnishings and furniture intended for use by the clients were observed to be sufficient and able to meet the needs of the clients at this time. A tour of the resident bathrooms was conducted. Hot water temperatures were taken and measured at 109.4*F which is within the allowed range of 105-120 degrees. A tour of the exterior grounds was conducted. {Cont. on 809C)

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael Bilger	TELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2021

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: 12/16/2021

NARRATIVE

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Side gates, and walkways were observed to be maintained in compliance at this time. Carbon Monoxide detectors and fire alarms and smoke detectors are in working order. Window screens were observed to be in good repair at this time. Water fountain in hallway has been removed and ceiling tiles have been replaced. Hazard materials observed to be inaccessible to residents in care. Signal system was tested and observed to be functional, with staff response time within 30 seconds. Resident rooms with oxygen observed to have appropriate signage on doors. Chair lifts noted in each stairwell during today’s visit. LPA received updated resident roster. Ceiling tiles and drywall on second floor has been replaced. Flooring on second floor is replaced.

This facility has been found to be in compliance at this time.
There were no deficiencies observed during today's Pre-licensing visit. Component III completed with Administrator Alma Whitted with applicant’s permission via phone during visit. Exit Interview conducted with Alma Whitted. A copy of this report was left with the Alma.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael Bilger	TELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2021

LIC809 (FAS) - (06/04)

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