397004353-4-5-2023-27-AS-ECUL-CR2Q69-20230419115308

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 397004353
Report Date: 03/30/2023
Date Signed: 04/05/2023 11:57:27 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/27/2023 and conducted by Evaluator Albert Johnson

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20230227122059

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: 52	DATE:	03/30/2023
		UNANNOUNCED	TIME BEGAN:	10:39 AM
MET WITH:	Rosa Marrero		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Staff do not prevent residents from engaging in an inappropriate interactions with other residents.

INVESTIGATION FINDINGS:

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Based on records reviewed, interviews with the staff and residents, R1 and R2 often argue with each other, staff, and other residents. Both R1 and R2 have had assessments with the facility staff, medical appointments and medication adjustments to assist with the behavior challenges that both residents are displaying.

The facility has made multiple attempts to address the episodes of the behaviors of both residents, the residents have had an increase in their rent which will support the additional staff to provide redirection when an antecedent is triggered. R1 is particpating in the Assisted Living Waiver Program (ALWP), this will allow the facility to get additional help with staffing to address the behaviors. R2 is not on the ALWP, however her rent was also increased to provide additional staffing to redirect any maladaptive behaviors and provide replacement strategies for more positive outcomes.

Unsubstantiated

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert Johnson	TELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20230227122059

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 03/30/2023

NARRATIVE

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The department could not corroborate the lack of effort to address the maladaptive behaviors of both residents. There appears to be due diligence with the facilities efforts and the LPA was able to verify the facilities efforts from records reviewed. This allegation is unsubstantiated.

Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove "Staff do not prevent residents from engaging in inappropriate interactions with other residents." The Department has determined that the allegation is unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed.

There are no deficiencies noted or cited per California Code of Regulations, TITLE 22.

Exit interview was conducted

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert Johnson	TELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023

LIC9099 (FAS) - (06/04)

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