397004353-7-22-2021-27-AS-CACL-C5QNQ5-20210809103920

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 397004353
Report Date: 07/22/2021
Date Signed: 07/22/2021 10:42:23 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/04/2020 and conducted by Evaluator Kevin Gould

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20201104154132

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:	DATE:	07/22/2021
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Brianna Chopus		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Neglect/Lack of Supervision:
1) Resident fell while in care
2) Resident's needs are not being met
Personal Rights:
1) Staff are not following doctor's orders

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kevin Gould made an unannounced inspection to Arbor Place RCFE Group Home on 7/22/21 at 9:45am to conclude the investigation of the above allegations and to deliver the findings. LPA met with Staff Brianna Chopus and together discussed the investigation details.

Based on the interviews and statements obtained during the investigation process, the allegations cannot be substantiated because LPA could not corroborate any allegations listed above. LPA Conducted interviews with staff members and caregivers who provided care to R1 (see confidential name list LIC-811 dated 7/22/21) All staff interviewed denied that R1 had a history of falling and that R1 had only fallen one time out of her wheelchair. All staff were consistent in their statements and LPA was unable to interview R1 due to diagnosed communication barriers. This allegation is unsubstantiated. LPA also interviewed direct care staff and LPA attempted to interview RP for additional information regarding R1's needs not being met. No staff interviewed identified any of R1's needs that are not being met. RP did not return call for interview.

Report continued on LIC 9099-C. Page 1 of 2

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021

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

LIC9099 (FAS) - (06/04)

Page: 1 of 2

Control Number 27-AS-20201104154132

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/22/2021

NARRATIVE

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LPA was unable to interview R1 to corroborate staff statements. This allegation is unsubstantiated. LPA discussed efforts the facility made with the Facility Administrator to locate a higher level of Care for R1 as ordered by her physician. LPA obtained electronic communications with Skilled Nursing Facilities in the area that discussed transferring R1 to a higher level of care. LPA attempted to follow up with correspondents with no success. The department could not corroborate the efforts made by the facility to relocate R1 but obtained some communications that verified their efforts. This allegation is unsubstantiated.

Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of Neglecty/Lack of Supervision and Personal Rights are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed.

There are no deficiencies noted or cited per California Code of Regulations, TITLE 22.

Exit interview was conducted with S1. Appeal Rights were issued, and a copy of this report was left at the facility.

Page 2 of 2.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 2