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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397004353
Report Date: 05/17/2024
Date Signed: 05/17/2024 01:47:27 PM


Document Has Been Signed on 05/17/2024 01:47 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: 58DATE:
05/17/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Frances SantillanTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Avelina Martinez arrived at facility unannounced to conduct a case management visit on 05/17/2024 at 11:45 AM. LPA Martinez met with Frances Santillan 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. five out of five 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 May 2024. LPA Martinez reviewed the facility's April Incident reports at the facility.
  • Tour Physical Plant.
  • AWOL's: Resident 1 (R1) left the facility on 04/11/2024. Around 5:15 PM, R1 did not not go to dinner, and facility staff began searching for R1. Local Law Enforcement was called, and R1 was found 1 mile away from the facility. Resident was found at 7:00 PM and returned to the facility by Local Law Enforcement.

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, Hospice, Medication/Incidental-Medical, and Resident Rights. In-service trainings were on offered this year.

A deficiency was cited at this visit, which can be found on the 809D page. 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: 05/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2024
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 05/17/2024 01:47 PM - 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: 05/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/20/2024
Section Cited
HSC
1569.312(e)

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1569.312(e) Basic services requirements: Monitoring the activities of the residents while they are under the supervision of the facility to ensure their general health, safety, and well-being. This requirement was not met as evidence by: Based on file review and interviews, the Licensee did not ensure
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Facility staff agrees to complete Dementia training for all employee and traning on basic services by 05/31/2024. Facility staff agrees to email traning agenda to LPA Martinez by 05/20/2024 by 5:00 PM. Email training documents by 05/31/2024 5:00 PM.
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the safety and well-being of R1 was being monitored, as R1 eloped from the facility and was found by LPD and returned to the facility by LPD. R1 was missing for approximately 2 hours. This posed an immediate health and safety risk to R1.
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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: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2