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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700997
Report Date: 03/30/2022
Date Signed: 03/30/2022 06:58:56 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/18/2022 and conducted by Evaluator Maja Jensen
COMPLAINT CONTROL NUMBER: 27-AS-20220118104227
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: 50DATE:
03/30/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Alma WhittedTIME COMPLETED:
06:00 PM
ALLEGATION(S):
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Personal Rights
INVESTIGATION FINDINGS:
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On 3-30-22 at 10:00am Licensing Program Analysts (LPAs) Maja Jensen and Michael Bilger arrived at facility unannounced to continue a complaint investigation and deliver complaint findings for the allegations noted above. LPAs were allowed access to the facility and screened at the front door for COVID symptoms. LPAs Jensen and Bilger met with Administrator Alma Whitted and Resident Care Coordinator and informed of the purpose of today's visit.

LPAs Maja Jensen and Michael Bilger conducted interviews with 5 residents and 4 staff members. In addition LPA Maja Jensen observed the interactions between staff and residents during the course of three visits, specifically on 1/24/22, 2/25/22 and 3/30/22. The personal rights allegation is related to the accusation that staff is speaking to residents in a disrespectful manner.
Based on the interviews conducted there was no coroboration that a violation of personal rights occurred and the preponderance of evidence standard was not met therefore this allegation is UNSUBSTANTIATED. An exit interview was conducted with Alma Whitted, and a copy of this report was left with facility.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/18/2022 and conducted by Evaluator Maja Jensen
COMPLAINT CONTROL NUMBER: 27-AS-20220118104227

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: 50DATE:
03/30/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Alma WhittedTIME COMPLETED:
06:00 PM
ALLEGATION(S):
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Insufficient staffing to meet the needs of the residents
INVESTIGATION FINDINGS:
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On 3-30-22 at 10:00am Licensing Program Analysts (LPAs) Maja Jensen and Michael Bilger arrived at facility unannounced to continue a complaint investigation and deliver complaint findings for the allegations noted above. LPAs were allowed access to the facility and screened at the front door for COVID symptoms. LPAs Jensen and Bilger met with Administrator Alma Whitted and Resident Care Coordinator (RCC) and informed of the purpose of today's visit.

LPAs Michael Bilger and Maja Jensen reviewed staffing schedules, actual hours worked, COVID screening logs, hourly check logs, and staffing disciplinary documentation. In addition LPAs also conducted interviews with 5 staff members and 5 residents.

LPA reviewed facility staff schedule for January 2022 during a COVID outbreak, actual hours worked, and interviewed RCC. Based on the records reviewed and interviews conducted it was determined that insufficient staffing occurred on 1-11-22. {Cont. on 9099C}
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20220118104227
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 03/30/2022
NARRATIVE
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Additionally, based on interview, it was determined that on 3-12-22 a staff member was absent from the floor for a period of 2.5 hours creating an insufficient staffing event.

Based on interviews conducted and records reviewed, the preponderance of evidence standard is met. Therefore, this allegation is SUBSTANTIATED.

An exit interview was conducted with Alma Whitted and a copy of this report was left with Alma. Appeal rights provided.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20220118104227
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 03/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/31/2022
Section Cited
CCR
87411(a)
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Personnel Requirements - General

(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.
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Licensee will submit a plan to ensure sufficient staff is available to meet resident needs by POC due date.
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This requirement was not met as evidenced by: Based on interviews and record reviews, staff was not scheduled and available during the dates of 1/11/22. Additionally, a staff member who was on schedule was absent from care for 2.5 hours on 3-12-22. This poses an immediate 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: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4