397004353-1-20-2023-27-AS-MBIR-CNA2EY-20230120162043

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 397004353
Report Date: 01/20/2023
Date Signed: 01/20/2023 04:20:49 PM

Document Has Been Signed on 01/20/2023 04:20 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 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: 51	DATE:	01/20/2023
TYPE OF VISIT:	Case Management - Health Checks	UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Belinda Guzman		TIME COMPLETED:	04:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 1-20-23 at 1:15 pm, Licensing Program Analyst ( LPA) Michael Bilger arrived at this facility unannounced to conduct a quarterly health and safety check visit. LPA was greeted by Administrator Belinda Guzman, and LPA explained the purpose of the visit. LPA Bilger inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, common areas, and outside of the facility to ensure compliance with Title 22 regulations. Facility is a 76-bed residential facility for the elderly with a current census of 51. LPA was screened upon entry for temperature and asked to sign in. COVID screening questions were asked prior to entry. All knives, toxins, and other chemicals were inaccessible to residents in care. Resident rights posted. No obstructions to emergency exits noted. The facility has submitted a COVID mitigation plan. The facility has central entry point and has implemented screening and sign in procedures at the front door area. LPA observed the facility to have hand washing, COVID - 19 informational, and social distancing signs posted throughout the facility, on the front door, and back yard. The facility has a designated infection control lead. The facility is able to designate and dedicated a Covid-19 room/bathroom if needed. Common touch surfaces are cleaned after each use. LPA observed all staff to be wearing masks during visit. LPA observed facility to be clean and sanitary with no foul odors or disrepair items noted. There were 4 staff on duty which includes med tech during LPA's visit today. LPA reviewed 10 staff charts. 3 of 10 staff files were new staff. New staff files contained required initial staff training and other contents. Remaining 7 staff files reviewed contained all appropriate contents including annual training and dementia training. Absence without leave (AWOL) procedures reviewed and observed to be included in training curriculum. Sign in and sign out sheets for residents in care were in place and complete. Reporting requirements reviewed and found to be in compliance. Updated list of AWOL risk residents was reviewed. {cont. on 809C}.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael Bilger	TELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023

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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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
	VISIT DATE: 01/20/2023

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LPA conducted facility tour and did observe physical defects. Floors and walls were clean and sanitary. Adequate lighting was noted throughout. Med room was locked and secured. Sign in and sign out procedures as well as COVID precautions were observed during tour. Kitchen area was clean and sanitary. Water temperature was between 105*F-120*F. Facility temperature read 75*F on thermostat.

No deficiencies cited today. An exit interview was conducted with Belinda Guzman and a copy of this report was provided to Belinda.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael Bilger	TELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023

LIC809 (FAS) - (06/04)

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