397004353-3-5-2024-27-AS-KHOS-D34HML-20240306051918

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 397004353
Report Date: 03/05/2024
Date Signed: 03/05/2024 01:59:16 PM

Unsubstantiated

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
12/12/2023 and conducted by Evaluator Avelina Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20231212095946

FACILITY NAME:	ARBOR PLACE		FACILITY NUMBER:	397004353
ADMINISTRATOR:	BELINDA GUZMAN		FACILITY TYPE:	740
ADDRESS:	17 LOUIE AVE		TELEPHONE:	(209) 369-8282
CITY:	LODI	STATE: CA	ZIP CODE:	95240
CAPACITY:	76	CENSUS: 56	DATE:	03/05/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Belinda Guzman		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Staff are not addressing a resident's change in condition.
Staff are preventing resident from seeking medical attention.

INVESTIGATION FINDINGS:

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On 03-05-2024 at 9:00 AM, Licensing Program Analyst (LPA) Avelina Martinez conducted an unannounced facility visit to deliver complaint findings. LPA Martinez met with Belinda Guzman and explained the purpose of today's visit.

During today’s visit, LPA Martinez obtained facility records and conducted interviews. During the record review, it was learned resident 1 (R1) was admitted into this facility on November 13, 2023. R1's initial pre-assessment indicates R1 has a history of falls. R1 can ambulate independently with a slow steady gate while they are in their room. R1 is reminded to use their wheelchair when they are in the facility community. Furthermore, R1 is reminded to use call light while they are in their room. R1's furniture is fixed to the wall for fall safety and frequent checks are conducted.

Continued...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 03/05/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20231212095946

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: 03/05/2024

NARRATIVE

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Moreover, facility records indicate R1 fell on December 10, 2023 with no injuries. R1 fell on December 11, 2023, and R1 was sent to the hospital. R1 was admitted into the hospital on December 12, 2023 and discharged on December 17, 2023. On December 20, 2023, R1 had a medical appointment. Additionally, R1 had lab work on February 14, 2024 and had a medical appointment on February 28, 2024. At this time, R1 does not have any scheduled medical appointments. On March 05, 2024, LPA Martinez observed R1 ambulate and complete transfers independently. It was also learned R1 has not had a health condition change in regards to falls, as R1 moved into the facility as a fall risk resident. In addition, R1's pre-assessments indicated R1 has a history of falls. The facility's Needs and Service Plan has fall prevention measures in place.

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.

An exit interview was conducted, and a copy of this report was provided to the facility.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 03/05/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2024

LIC9099 (FAS) - (06/04)

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