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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397004353
Report Date: 07/13/2023
Date Signed: 07/13/2023 01:36:52 PM


Document Has Been Signed on 07/13/2023 01:36 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
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: 54DATE:
07/13/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Belinda Guzman, AdministratorTIME COMPLETED:
02:00 PM
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On 07/13/2023, Licensing Program Analyst (LPA) Renee Campbell and LPA Victoria Brown arrived unannounced at 8am to conduct a Health and Safety visit to the facility. Upon arrival, residents were seen lined up in front of the dining room before breakfast. LPAs met with Rosa Marrero, Office Manager and explained the purpose of the visit. The Administrator Belinda Guzman was contacted and arrived within an hour to assist with todays visit. LPAs observed and reviewed the following areas during todays visit:
1. A continued plan ensuring appropriate care and supervision based on residents’ specific needs
- LPA's reviewed 6 resident Appraisal/Needs and Service Plans that were signed and dated.
2. Ensure continued completed training on the topic of care and supervision
-The Annual Schedule for In-Service training for current employees. Training that was completed was crossed out. Individual training requirements for new employees.
3. Reporting requirements to appropriate persons timely
-LPA Campbell observed and received recent incident/death reports. Facility is to continue to report any areas of concern with physical plant and/or residents by fax.
4. Absence w/o Leave (AWOL) procedures and staff training to include all existing and newly hired staff.
-LPA's observed that the In-Service training for existing staff included Absent Without Leave (AWOL) training to be conducted in July 2023. AWOL training is also included in the New Hire Orientation and has been conducted for new staff within the last month.
5. Updated resident list of who can leave unassisted
-A list of residents of who are allowed out of the facility unassisted per Physician Report (LIC602) was provided during this visit.
6. Sign in and sign out sheet to ensure its completeness and accuracy
-LPAs observed an updated sign-in/out sheet.
7. Updating appraisal forms and needs and service plans to reflect residents' current needs and associated interventions.
-LPAs observed pre-placement, residential appraisal, and Appraisal/Needs and Service Plans for 6 random resident files that were found to be completed, signed, and dated
SUPERVISOR'S NAME: Emerita CurielTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: 916-206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 07/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/13/2023
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: 07/13/2023
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Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited during this visit. An exit interview was conducted and a copy of the report given.
SUPERVISOR'S NAME: Emerita CurielTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: 916-206-6380
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023
LIC809 (FAS) - (06/04)
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