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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700997
Report Date: 02/25/2022
Date Signed: 03/16/2022 03:34:09 PM


Document Has Been Signed on 03/16/2022 03:34 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 03/16/2022 10:46 AM

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

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On 2/25/22 LPAs Maja Jensen and Avelina Martinez conducted a case management visit. During the course of this case management LPAs toured resident rooms and conducted facility interviews.

The purpose of the case management visit is to follow up on deficiencies found during complaint investigation 27-AS-20220222163759.

Resident 2 (R2) was observed to have malfunctioning call buttons in their room. LPA Avelina Martinez tested the call button system and it was observed that the living room and bedroom call buttons were transposed. In addition LPA Jensen observed a resident room was converted to an office. As a result facility sketch does not reflect this change.

Moreover LPA Jensen reviewed hourly check logs for 3 residents. It was observed that the one hour and two hour check logs for three residents had missing entries for 2/10, 2/11, 2/16, 2/17, 2/22 and 2/23. As a result residents are not receiving the required care.

As a result of this visit, the following deficiencies were cited, per Title 22 Regulations. The deficiencies were cited on 809-D.

An exit interview was conducted and a copy of this report was given with appeal rights
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 02/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2022
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 3


Document Has Been Signed on 02/25/2022 06:00 PM - It Cannot Be Edited

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: 02/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/11/2022
Section Cited

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A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal specified in Section 87457, Pre-admission Appraisal and providing the other basic services specified below, either directly or through outside resources
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This requirement was not met as evidenced by based on observationa and record review of R3, R4 and R5 hourly check log did not reflect that residents were being checked hourly therefore residents did not receive the required care. This poses a potential health and safety risk to residents R3, R4 and R5
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Type B
03/11/2022
Section Cited

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Plan of Operation87208(a)(7)(B) Each facility shall have and maintain a current, written definitive plan of operation...Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval..Sketches, showing dimensions, of the following:
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The grounds showing buildings, driveways, fences, storage areas, pools, gardens, recreation area and other space used by the residents.This requirement was not met as evidenced by based on observation resident room 119 is being utilized as an office for staff. This poses a potential health and safety risk for 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: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 02/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 02/25/2022 06:00 PM - It Cannot Be Edited

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: 02/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/11/2022
Section Cited

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87303 i(1)(A) Maintenance and Operation
Facilities shall have signal systems which shall meet the following criteria:
(1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall:
(A) Operate from each resident's living unit.
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This requirement was not met as evidenced by based on observation call button page alert displaying misinformation. This posed a potential threat to the Health, Safety, and Personal Rights of all 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: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 02/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2022
LIC809 (FAS) - (06/04)
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