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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397004353
Report Date: 07/24/2024
Date Signed: 07/24/2024 11:58:44 AM


Document Has Been Signed on 07/24/2024 11:58 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: 61DATE:
07/24/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
09:53 AM
MET WITH:Belinda GuzmanTIME COMPLETED:
12:00 PM
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On 7-24-2024 at 9:53am, Licensing Program Analyst (LPA) Michael Bilger arrived at this facility unannounced to conduct a quarterly health and safety visit. LPA met with the administrator Belinda Guzman and explained the purpose of the visit.

LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry area, living area, common TV area, and outside of the facility to ensure compliance with Title 22 regulations. Facility is a residential facility for the elderly (RCFE) with a current census of 61. Facility staffs 3 caregivers and 2 med techs on AM shift, 2 caregivers and 1 med tech on PM shift, and 1 caregiver and 1 med tech on NOC shift.

Room temperature reads 75*F. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished with no foul odors noted. Smoke and carbon detectors were in good repair. Facility has an emergency food and water kit. All toxins and other dangerous items including sharp objects were locked and inaccessible to residents in care. Medication storage area was observed to be locked and inaccessible to residents in care. LPA observed wander guard system to be functioning properly in all 8 sections of facility with adequate audible sound in place. Wander guard system contains alarms on each door and transmitters for select residents identified as exhibiting wandering behavior. A main transmitter is placed at the med station to inform staff of location of triggered alarms. Training for absence without leave (AWOL) was observed to be completed in 5 of 5 staffing files reviewed. LPA observed stipulation and waiver available for public viewing. Incident reports reviewed revealed 21 incidents for June 2024 and 9 incidents thus far for July 2024. All incident reports were sent to licensing department as indicated.

{Cont. on 809C}
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: (916) 862-4722
LICENSING EVALUATOR SIGNATURE:
DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2024
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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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
VISIT DATE: 07/24/2024
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During this inspection 5 resident files and 5 staffing files were reviewed for regulatory compliance. All files contained required contents including staff training requirements. Resident files reviewed contained all required contents including updated admission agreements, medical assessments, and updated appraisal forms as required.

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was held and a report was given to Administrator Belinda Guzman
SUPERVISOR'S NAME: Liza KingTELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: (916) 862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024
LIC809 (FAS) - (06/04)
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