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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700997
Report Date: 01/24/2022
Date Signed: 01/24/2022 03:32:28 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 LIVINGFACILITY NUMBER:
392700997
ADMINISTRATOR:WHITTED, ALMAFACILITY TYPE:
740
ADDRESS:6037 N. PERSHING AVENUETELEPHONE:
(916) 759-1969
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY:160CENSUS: 57DATE:
01/24/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Carla Little, Community Relations DirectorTIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analysts (LPAs) T. White and M. Jensen made an unannounced visit on this day for the purpose of conducting a Case Management, Health and Safety visit. LPAs met with Carla Little, Community Relations Director and explained the purpose of the visit.

LPAs toured the facility, including but not limited to, bedrooms, bathrooms, kitchen, and common areas. LPAs verified that the facility had running water and electricity. LPAs observed sufficient PPE supplies. LPAs inspected food supplies and observed 7 days worth of perishable and 2 days worth of non-perishable foods.

The following deficiencies was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in civil penalties.



An exit interview was conducted with Community Relations Director. A copy of this report and Appeal Rights given.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana WhiteTELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2022
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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: CAMLU ASSISTED LIVING
FACILITY NUMBER: 392700997
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/25/2022
Section Cited

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87309(a): Storage Space: (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
This requirement was not met as evidence by:
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Based on observartion, facility did not comply with the section cited above. LPAs observed unlocked tools and chemicals accessible to residents which is an immediate health and safety risk to residents in care.
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Type B
01/28/2022
Section Cited

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87303(a): Maintence and Operation :(a) The facility shall be clean, safe, sanitary and in good repair at all times...
This requirement was not met as evidence by:
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Based on observation, Facility did not comply with the section cited above in 87303(a). LPAs observed debris and cob webs throughout the facility, which is a potential health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana WhiteTELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2022
LIC809 (FAS) - (06/04)
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