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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397004353
Report Date: 11/03/2023
Date Signed: 11/03/2023 11:35:52 AM


Document Has Been Signed on 11/03/2023 11:35 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 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: 55DATE:
11/03/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Belinda GuzmanTIME COMPLETED:
12:00 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
Licensing Program Analyst (LPA) Avelina Martinez arrived at this facility unannounced on 11/03/2023 at 11:00 AM to conduct a case management visit. LPA Martinez met with Belinda Guzman and explained the purpose of the visit.

The purpose of the visit is to follow up on learned deficiencies during complaint investigation 27-AS-20231017085843. It was learned facility staff were taking resident (R2) and resident 3's (R3) briefs and giving them to other residents. The facility did not safeguard R2 and R3's personal property.

The following deficiency was observed and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. An exit interview was conducted, and copy of this 809 report, 809D page, and appeals rights were given to the facility.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2023
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 11/03/2023 11:35 AM - 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: ARBOR PLACE
FACILITY NUMBER: 397004353

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/03/2023
Section Cited
CCR
87217(b)

1
2
3
4
5
6
7
87217(b)Safeguards for Resident Cash, Personal Property, and Valuables:Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff. This requirement was not met as
1
2
3
4
5
6
7
Administrator has conducted a personal property in-service training on 09/18/2023 and 10/19/2023. In addition, the Administrator has conducted meetings with staff in regards to using facility's brief supply for residents. POC cleared on 11/03/2023.
8
9
10
11
12
13
14
 evidence by: based on interviews and file review, it was learned the Licensee did not ensure staff were properly trained on safeguarding residents personal property and not using R2 and R3 briefs on other residents. This posed a potential health and safety risk to R1 and R2
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2