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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 397004353
Report Date: 11/03/2023
Date Signed: 11/03/2023 11:34:50 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/17/2023 and conducted by Evaluator Avelina Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20231017085843
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
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Belinda GuzmanTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff asked resident to borrow money.
INVESTIGATION FINDINGS:
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On 11/03/2023 at 11:00 AM, Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced to deliver complaint findings. LPA Martinez met with Belinda Guzman during today’s visit and explained the purpose of today’s visit.

Throughout the course of the investigation, LPA Martinez conducted interviews and reviewed facility documents. The investigation revealed on one incident staff 1 (S1) borrowed $100.00 from resident 1 (R1). R1 informed the facility Administrator about loaning S1 $100.00. The facility Administrator held a meeting with S1 in regards to the $100.00 loan. Moreover, S1 was given a disciplinary action notice for borrowing money from a resident, and it was learned S1 no longer is employed at Arbor Place facility. Furthermore, R1 reported S1 did pay back the $100.00 loan.

Continued...
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/17/2023 and conducted by Evaluator Avelina Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20231017085843

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
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Belinda GuzmanTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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2
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9
Staff did not provide a safe and comfortable environment for residents.
Facility staff stole resident’s personal belongings.
Resident hospitalized multiple times due to another resident smoking on the premises.
INVESTIGATION FINDINGS:
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On 11/03/2023 at 11:00 AM, Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced to deliver complaint findings. LPA Martinez met with Belinda Guzman during today’s visit and explained the purpose of today’s visit.

Throughout the course of this investigation, LPA Martinez reviewed facility records and conducted interviews. LPA Martinez interviewed five residents. Four out of five residents reported they feel safe at the facility. One out five residents reported they could not answer the question, and they did not know if the facility was safe or not. Due to information provided by residents, there was not enough evidence to prove the facility is unsafe.

continued...
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20231017085843
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 11/03/2023
NARRATIVE
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Moreover, resident 2 (R2) reported staff 2 (S2) went into their room, and took their briefs. S2 reported the briefs were given to another resident. R2 reported there was a misunderstanding between them and S2. R2 reported S2 believed they were okay with sharing their briefs. R2 indicated they spoke with S2 and the Administrator, and informed them they are not willing to share their briefs. The facility replaced the briefs. In addition, resident 3 (R3) reported staff 3 (S3) asked if they could take one of their briefs. R3 reported they agreed to give a brief to another resident.

R3 reported the facility replaced their brief supply. The Administrator informed LPA Martinez that the facility has a supply of briefs for residents in care, and staff have been made aware of the brief supply. The Administrator reported that staff were provided an in-service training in regards to personal belongings. The Administrator also reported the facility replaced R2 and R3's brief supply. There was not enough evidence to prove staff were purposely stealing briefs from R2 and R3. However, please see November 03, 2023 809 Case Management report for safeguarding residents personal belongings.

R2 reported they were hospitalized on August 23, 2023 and August 24, 2023. R2 reported they were hospitalized for breathing issues, but was diagnosed with AFIB and high blood pressure. R2 reported after the August 2023 hospitalization, they have not returned to the hospital for breathing issues. R2 also reported they will be moving into another room away from resident 4 (R4) who smokes in the facility. Per gathered information it was learned R2 did not have multiple hospitalizations due to R4 smoking in the facility.

Due to the above noted information, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, and therefore the allegations are unsubstantiated.
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
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20231017085843
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
87468.2(8)
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87468.2(8) Additional Personal Rights of Residents in Privately Operated Facilities: To be free from neglect, financial exploitation... This requirement was not met as evidence by:
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Administrator has conducted a residents rights in-service training on 10/19/2023. POC cleared on 11/03/2023.
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Based on interviews and file review, the Licensee did not ensure R1's was protected from S1 financial exploitation behaviors. This posed a potential health and safety risk to R1 and other residents in care.
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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
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 27-AS-20231017085843
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 11/03/2023
NARRATIVE
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As a result of this investigation, the Department finds this allegation to be Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiency cited on the LIC 9099-D, per Title 22 Regulations.

An exit interview was conducted, and a copy of the 9099 report, LIC 9099-D, and appeal 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
LIC9099 (FAS) - (06/04)
Page: 4 of 5