397004353-9-17-2021-27-AS-LKIG-C7ZKS4-20211021080853

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 397004353
Report Date: 09/17/2021
Date Signed: 09/17/2021 12:02:59 PM

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
09/09/2021 and conducted by Evaluator Mohamed Filouane

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20210909101653

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: 41	DATE:	09/17/2021
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Belinda Guzman		TIME COMPLETED:	12:10 PM

ALLEGATION(S):

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Resident awoled from the facility.
Facility staff were not aware of resident's whereabouts.

INVESTIGATION FINDINGS:

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On 09/17/21, Licensing Program Analyst (LPA) Mohamed Filouane, conducted a 10-day complaint on-site inspection. LPA entered the facility and had his temperature taken and answered a COVID-19 questionnaire by a staff member, following the facility's health and safety procedures. LPA Filouane then met with Executive Director (ED) Belinda Guzman, explained the purpose of the visit, reviewed the allegations, and closed the complaint on the same day.

During the investigation, LPA Filouane interviewed the Executive Director regarding the two above mentioned allegations and requested background information. The ED stated the AWOL had occurred during the facility's COVID-19 lockdown, likely around the facility's dinner time. LPA confirmed this information from the incident report. The ED stated facility staff had witnessed the resident covering the WanderGuard on the resident's wrist after the AWOL situation occurred; facility staff suspect the action of covering the WanderGuard can silence the alert.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Mohamed Filouane	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2021

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

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20210909101653

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: 09/17/2021

NARRATIVE

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After the AWOL situation, the facility has placed an additional WanderGuard on the resident in question's ankle, as a precaution to prevent further AWOLs. LPA Filouane verified that the resident was not allowed to leave the facility alone and that the incident report of this AWOL was not submitted to the Community Care Licensing Division, as required under Title 22 regulations. After review, the above mentioned allegations are substantiated.

Based on LPA’s observations, record review, and interview, which were conducted along with a file review, the preponderance of evidence has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6 & Chapter number 8) is being cited on the attached LIC 9099D.

Exit interview conducted with the Executive Director. The Executive Director will receive a copy of this signed report through email.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Mohamed Filouane	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 27-AS-20210909101653

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/17/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/20/2021 Section Cited CCR 87211(A)(2)	1 2 3 4 5 6 7	Reporting Requirements: Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following . . . Any incident which threatens the welfare, safety or health of any resident . . .	1 2 3 4 5 6 7	The Licensee shall ensure that staff are monitoring the entrance and exits of facilities and that the WanderGuards on residents are properly working, as well as the facility staff shall report to CCLD incidents under the required time frame. A statement shall be submitted to CCLD on what the facility has implemented to help prevent further AWOLs, as well as acknowledgement of the reporting requirements.
	8 9 10 11 12 13 14	This requirement has not been met as evidenced by: the Licensee failed to report the incident to the Community Care Licensing Division (CCLD) as required by Title 22.	8 9 10 11 12 13 14
Type A 09/20/2021 Section Cited CCR 87705(k)(8)	1 2 3 4 5 6 7	Care of Persons with Dementia Delayed egress devices shall not substitute for trained staff in sufficient numbers to meet the care and supervision needs of all residents and to escort residents who leave the facility.	1 2 3 4 5 6 7	The Licensee shall ensure that staff are monitoring the entrance and exits of facilities and that the WanderGuards on residents are properly working,
	8 9 10 11 12 13 14	This requirement has not been met as evidenced by: the Licensee failed to provide supervision and was not aware the resident had gone missing, which threatened the health and safety of the resident.	8 9 10 11 12 13 14

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: Mohamed Filouane	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2021

LIC9099 (FAS) - (06/04)

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