397004353-5-27-2021-27-AS-KHOS-C3LLN5-20210602085347

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 397004353
Report Date: 05/27/2021
Date Signed: 05/27/2021 12:34:48 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
07/03/2020 and conducted by Evaluator Jason Lund

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20200703102525

FACILITY NAME:	ARBOR PLACE		FACILITY NUMBER:	397004353
ADMINISTRATOR:	BELINDA GUZMAN		FACILITY TYPE:	740
ADDRESS:	17 LOUIE AVE		TELEPHONE:	(209) 369-8282
CITY:	LODI	STATE: CA	ZIP CODE:	95240
CAPACITY:	76	CENSUS: 42	DATE:	05/27/2021
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Administrator Belinda Guzman		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Facility not providing assistance with bathing.
Facility is not transferring the resident as needed.
Facility does not have adequate staffing to meet the needs of the residents.
Facility is not providing food of the quality and quantity to meet the resident's needs.

INVESTIGATION FINDINGS:

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On 5/27/2021, Licensing Program Analyst (LPA) Jason Lund arrived at the facility unannounced to complete a complaint investigation regarding the above allegations. LPA Lund meet with Administrator Belinda Guzman and explained the reason for the visit. Current Census

LPA Lund reviewed resident (R1) records, interviewed staff and witness regarding the allegations. R1 expired on 12/3/2020. R1 could not speak or communicate with staff or family members.

Based on the investigation through interviews and records, R1 Appraisal/Needs and Services Plan. R1 behavioral disturbances and anxiety disorder made it hard for staff to give showers to R1. Staff would give sponge baths to R1 instead of showers. R1 Power of Attorney (POA) and staff stated that she was able to transfer from bed to the walker or wheelchair.

Unfounded

Estimated Days of Completion: 90

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason Lund	TELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2021

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

Control Number 27-AS-20200703102525

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: ARBOR PLACE	FACILITY NUMBER: 397004353
	VISIT DATE: 05/27/2021

NARRATIVE

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Through interviews and records review, R1’s Preplacement Appraisal information stated that R1 could walk with a walker. Interviews stated that staff would walk R1 throughout the hallway. When not walking staff or R1 self would transfer R1 from bed to wheelchair to go watch TV and go to activities but R1 would not participate. The facility would use a two-person lift to get R1 out of bed when R1 could not transfer R1 self. Staff where trained to do a two-person lift.

Through interviews and records review. The facility staffing records for June through August 2020, show that the facility had constant staffing for all shifts to meet the needs of the residents. Residents interviewed stated that their needs are being met. Staff interviewed felt that they were able to meet the needs of the residents.

Through interviews and records review R1’s Appraisal/Needs and Services Plan stated that R1 would eat finger foods due to R1not being able to use utensils. The facility would make different kinds of foods that R1 could eat not using utensils. R1’s POA was aware that R1 could not use utensils to eat and had to eat food that R1 could pick up to eat.

This agency has investigated the complaint allegations. We have found the complaint was UNFOUNDED, meaning that the allegation is false, could not have happened, and/or is without a reasonable basis.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason Lund	TELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2021

LIC9099 (FAS) - (06/04)

Page: 2 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
07/03/2020 and conducted by Evaluator Jason Lund

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20200703102525

FACILITY NAME:	ARBOR PLACE		FACILITY NUMBER:	397004353
ADMINISTRATOR:	BELINDA GUZMAN		FACILITY TYPE:	740
ADDRESS:	17 LOUIE AVE		TELEPHONE:	(209) 369-8282
CITY:	LODI	STATE: CA	ZIP CODE:	95240
CAPACITY:	76	CENSUS: 42	DATE:	05/27/2021
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Administrator Belinda Guzman		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Facility leaves resident in soiled diapers for hours
Facility staff verbally abusive to resident

INVESTIGATION FINDINGS:

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A complaint investigation regarding the above allegations was completed by LPA Jason Lund.

Based on interviews with residents stated that staff would talk loud to the residents and they were not sure if the staff were yelling at them are talking loud to them. The residents interviewed stated that they never felt threatened by staff and apricated the assistance of the staff.

Unsubstantiated

Estimated Days of Completion: 90

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason Lund	TELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 27-AS-20200703102525

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: ARBOR PLACE	FACILITY NUMBER: 397004353
	VISIT DATE: 05/27/2021

NARRATIVE

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Based on the investigation and Resident (R1) passing way on 12/3/2020. LPA Lund was not able to observe R1’s grooming, showering or continence-incontinent (bowl and bladder). The facility objective was to check on R1 and other residents every two hours and change R1’s depends if necessary.

Although the allegation may be valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview was conducted with Administrator Belinda Guzman and a copy of report was left.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason Lund	TELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 4