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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397004353
Report Date: 08/25/2021
Date Signed: 08/25/2021 12:59:47 PM

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 PLACEFACILITY NUMBER:
397004353
ADMINISTRATOR:BELINDA GUZMANFACILITY TYPE:
740
ADDRESS:17 LOUIE AVETELEPHONE:
(209) 369-8282
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY:76CENSUS: 39DATE:
08/25/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Gurprit RaiTIME COMPLETED:
01:00 PM
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On 8/25/2021 at 9:30am, Licensing Program Analyst (LPA) Ashley Boothe, arrived announced to conduct a conduct a Health and Safety visit based on a report of COVID-19 outbreak. LPA met with Staff on (S1), Staff two (S2) and Staff three (S3) to tour the facility with Person one (P1), Infection Preventionist from California Department of Public Health Healthcare Associated Infections Program.

As of today 25 residents tested positive and 11 staff tested positive of which 1 staff has cleared and returned to work. Currently all residents are under isolation order due to the outbreak. The team discussed infection control measures and mitigation of COVID-19 in the facility including but not limited to screening, isolation, disinfection, and use off personal protective equipment (PPE). All facility staff have been fit tested for N95 respirators. P1 is to deliver a report to the facility based on observations and discussions during today's visit. The Regional Office will continue to monitor the facility. S1 requested PPE to be delivered to support on hand of PPE and LPA will coordinate delivery.

Per the California Code of Regulations, Title 22, Division 6, no deficiencies observed or cited. Exit interview held, copy of report given.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021
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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