397004353-7-28-2021-27-AS-TWHE-C5BU2M-20210727151210

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 397004353
Report Date: 07/27/2021
Date Signed: 07/28/2021 08:05:24 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

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: 47	DATE:	07/27/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:55 PM
MET WITH:	Gurpreet Rai, Assistant Administrator		TIME COMPLETED:	03:20 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 07/27/2021 at 1:45pm, Licensing Program Analyst (LPA) T. White spoke with Business Manager, Brianna Chopus, regarding facility risk assessment questions. Business Manager confirmed no staff or residents have experienced symptoms within the last 10 days. At 1:50pm, LPA T. White arrived unannounced to conduct a required 1-year annual inspection. LPA met with Gurpreet Rai, Assistant Administrator and explained the purpose of today’s inspection. LPA was allowed entry into the facility that is licensed to serve a total capacity of 76 ambulatory residents, which 31 can be non-ambulatory and 2 on hospice. LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and patio. All outdoor and indoor passageways are kept free of obstruction. A comfortable temperature is maintained at 76 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathrooms measured at 102, 103, 100.8, 99.7,109.2 and 108.3 degrees Fahrenheit. There is a minimum of 7-day supply of nonperishable and 2-day of perishable foods. Smoke detector is interconnected with the fire department. Fire Drill last conducted July 16, 2021. Fire extinguisher was last serviced on February 01, 2021. First aid kit was observed to be complete. LPA observed mitigation plan is completed. - LPA observed hot water temperature in 4 of 6 residents shared bathrooms measured below 105 degrees Fahrenheit. Report continues on 809C.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana White	TELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2021

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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: ARBOR PLACE	FACILITY NUMBER: 397004353
	VISIT DATE: 07/27/2021

NARRATIVE

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Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 08/03/2021:
LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan

The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in civil penalties.

Exit interview conducted with Assistant Administrator. A copy of report and appeal rights given.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana White	TELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2021

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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: ARBOR PLACE	FACILITY NUMBER: 397004353
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/27/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above in 87303(e)(2). LPA observed 4 of 6 residents shared bathroom faucets measured below 105 degrees F. which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/30/2021
	Plan of Correction
1 2 3 4	Assistant Administrator agreed to adjust hot water temperature and submit a 3 -day temperature log to CCL by POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana White	TELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2021

LIC809 (FAS) - (06/04)

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