<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397004353
Report Date: 08/18/2023
Date Signed: 08/18/2023 04:27:01 PM


Document Has Been Signed on 08/18/2023 04:27 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 PLACEFACILITY NUMBER:
397004353
ADMINISTRATOR:BELINDA GUZMANFACILITY TYPE:
740
ADDRESS:17 LOUIE AVETELEPHONE:
(209) 369-8282
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY:76CENSUS: 51DATE:
08/18/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Belinda GuzmanTIME COMPLETED:
04:45 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 8/18/23 at approximately 1:40pm, Licensing Program Analyst Maja Jensen arrived at facility unannounced to conduct a case management related to health and safety checks. LPA Jensen met with Administrator Belinda Guzman and explained the purpose of today's visit.

The Fire Marshal contacted the Community Care Licensing Department on 8/18/23 to advise that they received a complaint about a beam which is in danger of collapsing near an entrance to the facility. The complaint was received by the Fire Marshal on 8/17/23 and the Fire Marshal did an on site inspection the same day. The Fire Marshal determined that the beam poses an immediate danger and instructed the facility to section off and close the area until remediation work can be completed. The Fire Marshal returned the following morning (8/18/23) and observed that the area had not been closed off and witnessed staff members exiting and entering under the compromised beam. The Fire Marshal remained at the facility while the staff sectioned off the area under the pergola with the compromised beam.

LPA Jensen interviewed the Fire Marshal. The Fire Marshal stated based on the condition of the beam, it's safety has been compromised for a long period of time, likely in excess of a year.

Deficiencies are being cited from the California Code of Regulations (CCR) Title 22, Division 6. Failure to correct deficiencies may result in the assessment of civil penalties.

An exit interview was conducted and a copy of this report and appeal rights were provided.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 08/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 08/18/2023 04:27 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/18/2023
Section Cited
CCR
87303(a)

1
2
3
4
5
6
7
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
The Licensee agrees to schedule services with a contractor for emergency shoring of the beam and will email confirmation to liza.king@dss.ca.gov by 8/19/23. The Licensee further agrees to provide a comprehensive plan for remediation by 8/25/23.
8
9
10
11
12
13
14
Based on observation by the Fire Marshal and LPA Jensen the facility has a pergola at an entrance commonly used by staff and residents with a beam that has deteriorated to the point of becoming a safety hazard. This poses an immediate risk to the health, safety and personal rights of residents in care.
8
9
10
11
12
13
14
Type B
08/21/2023
Section Cited
CCR87405(h)(5)

1
2
3
4
5
6
7
Administrator - Qualifications and Duties
...The administrator shall have the responsibility to:
Provide or ensure the provision of services to the residents with appropriate regard for the residents' physical and mental well-being and needs. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
The Licensee agrees that the administrator will sign and email an attestation that this regulation has been read, understood and will be complied with to maja.jensen@dss.ca.gov by 8/21/23.
8
9
10
11
12
13
14
Based on the Fire Marshal reporting that facility staff did not comply with urgency as directed in relation to securing an area where a wooden beam was in danger of collapsing. This poses a potential threat to the health, safety and personal rights of residents in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 08/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2