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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397004353
Report Date: 01/18/2024
Date Signed: 01/18/2024 01:55:19 PM


Document Has Been Signed on 01/18/2024 01:55 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: 57DATE:
01/18/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Belinda Guzman TIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Avelina Martinez arrived at facility unannounced to conduct a case management visit on 01/18/2024 at 1:00 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. 2 out of 2 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 January 2024.
  • Tour Physical Plant.
  • AWOL's: Belinda Guzman reported the facility has not had an AWOL.

Quarterly Visit Review:

LPA Martinez reviewed the 2024 Annual in-Service and Education Program report. It was learned the facility offered the following in-service training to staff: Dementia , Medication/Incidental-Medical, Resident Rights, and Blood Borne Pathogens. In-service trainings were on offered on 01/03/2024. Facility resident and staff files 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: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/18/2024
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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