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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397004353
Report Date: 10/11/2023
Date Signed: 10/11/2023 03:45:00 PM


Document Has Been Signed on 10/11/2023 03:45 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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: 52DATE:
10/11/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:26 PM
MET WITH:Belinda Guzman TIME COMPLETED:
03:50 PM
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Licensing Program Analyst (LPA) Avelina Martinez arrived at facility unannounced to conduct a case management visit on 10/11/2023 at 2:26 PM. LPA Martinez met with Belinda Guzman and explained the purpose of the visit.

The purpose of the visit today is to conduct a quarterly visit. LPA Martinez followed up with the following:
  • Care and Supervision. AM Shift three care staff PM two care staff Noc Shift 1 care staff. One Med-Tech per shift.
  • Resident Appraisals/Needs- and Service Plans. 5 out of 5 files were maintained
  • In-Service Training For All Staff. Staff documentation maintained and training provided to staff.
  • Reporting Requirements. LPA Martinez reviewed Community Care Licensing Department (CCLD) Unusual Incident Report (UIR) LIC 624 file for the month of September 2023. The Department received 2 UIR reports. Per Belinda LIC 624 have been emailed to LPA Campbell.
  • Tour Physical Plant.
  • AWOL's: Belinda Guzman reported the facility has not had an AWOL.

Quarterly Visit Review:

LPA Martinez reviewed the 2023 Annual in-Service and Education Program report. It was learned the facility offered the following in-service training to staff: Postural supports, dementia training, hospice services, physical limitations and personal care services, fire/disaster/emergency, missing resident policy and test, and corporate compliance. In addition, LPA Martinez reviewed five employee files. The files contained in-service training documentation. LPA Martinez reviewed five physician reports LIC 602. The physician reports were maintained.

No deficiencies were cited at this visit. An exit interview was conducted, and a copy of this report was provided to the facility.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2023
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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