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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 04:43:04 PM


Document Has Been Signed on 09/29/2022 04:43 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 - OtherUNANNOUNCEDTIME BEGAN:
01:44 PM
MET WITH:Rosa MarreroTIME COMPLETED:
02:30 PM
NARRATIVE
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On 9-29-22 at 1:44pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit relating to rate change notification. LPA met with assistant business office manager Rosa Marrero and explained the purpose of the visit. Administrator Belinda Guzman was notified of LPA’s visit and purpose via phone. LPA interviewed Administrator and assistant business office manager. LPA also reviewed level of care rate change noticed dated 7-18-22. Based on interview and record review, it was determined that resident1 (R1) received a rate increase due to level of care change effective 7-11-22. Further review reveals level of care rate increase was given one week after the effective level of care change. Additionally, notice given did not include an explanation of charges.

As a result of today’s case management, citation is issued under Health and Safety Code, chapter 3.2. 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 04:43 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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Rate increase…change in level of residents’ care...(a) For any rate increase due to a change in the level of care...the licensee shall provide the resident and the resident’s representative, if any, written notice of the rate increase within two business days after initially providing services at the new level of care. The notice shall include a detailed explanation of the additional services to be provided... and...itemization of the charges. This requirement is not met as evidenced by:
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Based on interview and record review, licensee did not ensure a proper level of care rate increase was given to R1’s representative. This posed a potential health, safety and resident rights risk to residents in care.
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 Licensee to submit a plan describing how residents’ and resident’s representatives will be notified properly of level of care rate increases. Plan to be submitted to LPA by POC due date.

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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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