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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397004353
Report Date: 09/29/2022
Date Signed: 09/29/2022 04:45:18 PM


Document Has Been Signed on 09/29/2022 04:45 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: 48DATE:
09/29/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Rosa TIME COMPLETED:
04:45 PM
NARRATIVE
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On 9-29-22, at 2:30pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct case management due to an incident which occurred on 9-8-22. LPA met with assistant business office manager Rosa Marrero and explained the purpose of the visit. Administrator Belinda Guzman was made aware of LPA’s visit and purpose via phone. LPA reviewed incident report and SOC 341 form. LPA also interviewed Administrator. Based on record review and interview, it was determined that on 9-8-22 resident1 (R1) stated $1800 was allegedly taken from his room which was placed under a mattress and also stated dresser drawers were open. Records review reveal that facility reported incident to department, ombudsman, and law enforcement for follow up. Facility updated R1's service plan. Upon further interviews, it was determined that staff searched R1’s room on 9-8-22 in an attempt to recover medications R1 allegedly kept unsecured. Interviews also determined that staff did not receive permission from R1 to enter and search room and R1 was not present with staff during search.

As a result of today’s visit. Citations are issued under Title 22, Division 6, Chapter 8. An exit interview was conducted with Rosa Marrero and a copy of this report was left with Rosa. Appeal rights explained and to be provided.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2022
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 09/29/2022 04:45 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: ARBOR PLACE
FACILITY NUMBER: 397004353

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/10/2022
Section Cited

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Additional Personal Rights of Residents…(a) In addition to the rights listed in Section 87468.1…(1)To have a reasonable level of personal privacy in accommodations…This requirement is not met as evidenced by:
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Based on interview, facility staff conducted a room search of R1 without consent. This posed a potential health, safety, and resident rights 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: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 09/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2022
LIC809 (FAS) - (06/04)
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