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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397004353
Report Date: 03/23/2023
Date Signed: 03/23/2023 09:26:05 AM


Document Has Been Signed on 03/23/2023 09:26 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 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: 53DATE:
03/23/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Belinda Guzman, AdministratorTIME COMPLETED:
09:30 AM
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LPA Campbell inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common TV area, and outside backyard of the facility to ensure compliance with Title 22 regulations. Facility is a 76-bed adult residential facility with a current census of 53. LPA was screened upon entry for temperature and asked to sign in. COVID screening signs were posted on door. Facility has 76 bedrooms with their own bathrooms. There is a formal living room and visiting area for residents. All knives, toxins, and other chemicals were inaccessible to residents in care. Facility evacuation plans are displayed on the walls.

The facility has a central entry point and has implemented screening and sign in procedures at the front door area. Employee self-screen for symptoms, and visitors are screened upon entry. Common touch surfaces are cleaned after each use. No spider webs or other evidence of insect infestation were visible. Light bulbs were operational in all resident rooms during today's visit. Medication pass was observed by LPA.

Hallways and resident rooms appeared clean. It was observed that laundry was being completed by staff. LPA observed the bottom floor/1st floor. Residents were being assisted by staff prior to breakfast being served, Kitchen Manager, Yolanda Martinez was present. The Breakfast menu for the day was accurate. Residents were served, Cream of Wheat, Cheesy eggs and orange slices.

Of the 8 caregivers on staff, 1 medication aide was present. LPA Campbell reviewed Inservice Training files for all staff. Staff have received training for Postural Supports, Medication Storage and Dementia Training since the beginning of the 2023.

An exit interview held with facility staff, and a copy of the report was given. No deficiencies were cited.
SUPERVISOR'S NAME: Emerita CurielTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: 916-206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 03/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2023
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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