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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397004353
Report Date: 06/25/2021
Date Signed: 06/25/2021 12:52:45 PM

Document Has Been Signed on 06/25/2021 12:52 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:ARBOR PLACEFACILITY NUMBER:
397004353
ADMINISTRATOR:BELINDA GUZMANFACILITY TYPE:
740
ADDRESS:17 LOUIE AVETELEPHONE:
(209) 369-8282
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY: 76CENSUS: 44DATE:
06/25/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Belinda Guzman, AdministratorTIME COMPLETED:
01:00 PM
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On 6/25/21 at 9:45pm Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced case management -Deficiencies inspection to address concerns regarding the placement of a resident identified as R1 who had a prohibited health condition and should not have been admitted to placement.

LPA reviewed R1's file and observed R1s Physician Evaluation Report (LIC 602a) dated 3/16/2020 which indicated that R1 had no capability of self care and that the R1 was also not receiving hospice services. Additionally, LPA Gould observed the appraisal and needs and services plan for R1 dated 4/3/2020 conducted by Administrator, Belinda Guzman which stated R1 needs assistance with all assistance with daily diving (ADLs) including but not limited to bathing, dressing and grooming, toileting, continence care, eating and physical conditions including speech and ambulatory impairments.

A resident who requires others to perform all activities of daily living and is not receiving hospice care is considered a prohibited health condition.

The following deficiency is cited per California Code of Regulations, Title 22.

An exit interview was conducted and a copy of this report and appeal rights were left at the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE: DATE: 06/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/25/2021
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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Document Has Been Signed on 06/25/2021 12:52 PM - It Cannot Be Edited


Created By: Kevin Gould On 06/25/2021 at 12:08 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: ARBOR PLACE
FACILITY NUMBER: 397004353

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/25/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/28/2021
Section Cited

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Prohibited Health Conditions: Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: Residents who depend on others to perform all activities of daily living for them as set forth in Section 87459, Functional Capabilities.
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This requirement was not met as evidenced by LPA's review of R1's Physician Evaluation Report and R1's appraisal conducted by the facility revealed that R1 had a prohibited health condition prior to placement at the facility which poses an immediate health and safety risk for resident 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:Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME:Kevin Gould
LICENSING EVALUATOR SIGNATURE:
DATE: 06/25/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/25/2021


LIC809 (FAS) - (06/04)
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