397004353-3-23-2023-27-AS-RCAL-CQ7N5L-20230323100944

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 397004353
Report Date: 03/23/2023
Date Signed: 03/23/2023 10:11:51 AM

Document Has Been Signed on 03/23/2023 10:11 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 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: 55	DATE:	03/23/2023
TYPE OF VISIT:	Case Management - Legal/Non-compliance	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Belinda Guzman, Administrator		TIME COMPLETED:	10:30 AM

NARRATIVE

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Licensing Program Analyst (LPA) Albert Johnson and LPA Renee Campbell conducted an unannounced complaint visit on 03/23/2023 to follow up on a substantiated allegation of lack of basic service requirements/knowledge of resident whereabouts that led to a resident elopement, resident intoxication, and serious bodily injury of a resident. LPA Albert Johnson met with Administrator Belinda Guzman and explained the reason for the visit.

On August 22, 2022, the Department concluded a complaint investigation and substantiated an allegation that Administrator and facility staff did not ensure facility’s knowledge of Resident 1’s (R1) whereabouts on May 17, 2022, which led to an elopement episode, intoxication, and head injury to R1.

The allegations were substantiated, and the Administrator was cited for violating Health and Safety Code section 1569.312(d) Basic Service Requirements. According to medical records obtained from a local acute hospital, R1 sustained left frontal lobe parenchymal contusions, subarachnoid hemorrhages, bilateral subdural hematomas, bilateral maxillary sinus fractures, and bilateral orbital fractures. According to medical records, R1 was diagnosed with an accidental fall, alcohol intoxication, dementia, facial bone fracture, and intracranial hemorrhage. According to medical records, R1 was admitted to the hospital on May 17, 2022, with an ethanol level of .227% which was labeled as “high.”

cont 809C

SUPERVISOR'S NAME: Emerita Curiel	TELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Renee Campbell	TELEPHONE: 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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: ARBOR PLACE	FACILITY NUMBER: 397004353
	VISIT DATE: 03/23/2023

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The Investigation revealed that on May 17, 2022, R1 eloped from the facility, became intoxicated, and fell outside facility boundaries sustaining a serious injury to their head. Upon review of R1’s physician report on August 5, 2022, dated December 23, 2021, and signed by physician; it was determined that R1 was not allowed to leave the facility unattended. Review of sign in and sign out log from May 17, 2022, did not indicate R1 or R1’s responsible person signed R1 out. Interview on July 26, 2022, also revealed that R1’s responsible party member did not observe resident in their room at approximately 2:30 p.m. during a visit on May 17, 2022. Incident report dated May 18, 2022, indicated facility staff noticed resident missing at approximately 4:45 p.m. on May 17, 2022, and were not aware of R1’s whereabouts at this time. The incident report also revealed facility staff learned of R1’s whereabouts at approximately 9:15 p.m. on May 17, 2022, from the police department which also included information of R1’s condition of intoxication and a head injury. An interview with Staff 1 (S1) on August 2, 2022, revealed R1 has a history of exiting the facility. Facility’s elopement policy reviewed on August 5, 2022, states “law enforcement authorities will be notified within 30 minutes should resident not be located.” Police report reviewed on August 5, 2022, and dated May 17, 2022, states R1 was reported missing at 7:02 p.m. on May 17, 2022, by Staff 2 (S2) after S2 discovered R1 not in R1’s room when S2 went to bring R1 dinner at approximately 5:00 p.m. Police report further states that they were made aware at approximately 9:10 p.m. that R1 was transported to the local hospital “earlier in the evening” of May 17, 2022.

Based on interviews and record reviews, it was determined that facility was unaware of R1’s whereabouts on May 17, 2022, leading to R1’s elopement, absence without supervision, intoxication, and injuries as noted above.

cont 809C

SUPERVISOR'S NAME: Emerita Curiel	TELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Renee Campbell	TELEPHONE: 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

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
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: ARBOR PLACE	FACILITY NUMBER: 397004353
	VISIT DATE: 03/23/2023

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At the time of the complaint visit, the issuance of an additional Civil Penalty was still being determined and the Administrator was informed that a civil penalty might be assessed based on Health and Safety Code section 1569.49. Health and Safety Code section 1569.49(f) states: for a violation that the department determines constitutes physical abuse, as defined in Section 15610.63 of the Welfare and Institutions Code, or resulted in serious bodily injury, as defined in Section 15610.67 of the Welfare and Institutions Code, to a resident, the civil penalty shall be ten thousand dollars ($10,000).

The Department has concluded an analysis and has determined that a Civil Penalty is warranted for Basic Service Requirements (Health and Safety Code section 1569.312(d)), for facility was unaware of R1’s general whereabouts leading to serious bodily injury. Today, 03/23/2023, the Department will be issuing a Civil Penalty per Health and Safety Code section 1548(f)(1)(A) for $9,500.

An exit interview was conducted, and a copy of this report was given to Administrator Belinda Guzman. Appeal Rights listed on the LIC421D were delivered and reviewed with Administrator Belinda Guzman.

SUPERVISOR'S NAME: Emerita Curiel	TELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Renee Campbell	TELEPHONE: 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

LIC809 (FAS) - (06/04)

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