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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 397004353
Report Date: 08/22/2022
Date Signed: 08/22/2022 11:58:28 AM

Substantiated


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
05/20/2022 and conducted by Evaluator Michael Bilger
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220520111216
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: 48DATE:
08/22/2022
UNANNOUNCEDTIME BEGAN:
10:04 AM
MET WITH:Belinda GuzmanTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Neglect/ lack of care and supervision resulted in resident going AWOL and sustaining an injury
Facility failed to notify law enforcement in a timely manner
Facility failed to report to responsible party that resident had left unattended
Staff not properly trained on AWOL procedures
INVESTIGATION FINDINGS:
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On 8-22-22 at 10:04am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver complaint findings for the allegations listed above. LPA met with Administrator Belinda Guzman via phone and explained the purpose of the visit. Belinda gave permission for Rosa Marrero, assistant business office manager to sign in her physical absence. During this investigation, LPA interviewed Administrator, four staff members and one resident. LPA also reviewed file documentation including Admission agreement for resident1 (R1), preplacement appraisal for R1, sign in and sign out sheet for 5-17-22, police report, needs and service plan for R1, staffing schedule for May, hospital discharge summary notes, incident report dated 5-18-22, emergency personnel transport report, dementia plan of operation, missing resident policy, face sheet for R1, physician’s report for R1, and additional medical records pertaining to R1’s health history. LPA also conducted a facility observation on 8-5-22. LPA conducted previous visits to the facility on 7-29-22 and 8-5-22.

Allegation #1: Neglect/lack of care and supervision resulted in resident going AWOL and sustaining and injury.
Based on interviews conducted and record reviews as noted above, it was determined that R1 eloped from facility on 5-17-22, became intoxicated, and fell outside facility boundaries sustaining a serious injury to head.

{Cont. on 9099C}
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2022
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 7
Control Number 27-AS-20220520111216
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: 08/22/2022
NARRATIVE
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Upon review of R1’s physician report signed by physician; it was determined that R1 was not allowed to leave facility unattended. Review of sign in and sign log did not indicate R1 or R1’s responsible person signed R1 out. Interviews and record reviews further determined that R1 had a history of exiting facility multiple times unattended, and a history of eloping from previous facilities. Interviews also revealed that R1’s responsible party member did not observe resident in his room at approximately 2:30pm during a visit on 5-17-22. Incident report dated 5-18-22 indicated facility staff noticed resident missing at approximately 4:45pm on 5-17-22, and were not aware of R1’s whereabouts. Incident report also revealed facility staff learned of R1’s whereabouts at approximately 9:15pm from police department which also included information of R1’s condition of intoxication and head injury. A review of hospital discharge summary stating an admission date of 5-17-22 and a discharge date of 5-27-22 revealed R1 sustained Left frontal lobe parenchymal contusions, subarachnoid hemorrhages, bilateral subdural hematomas, bilateral maxillary sinus fractures, and bilateral orbital fractures. Discharge summary also stated an ethanol level of .227% and labeled as “high” in the document. Based on interviews and record reviews, it is determined that facility was unaware of R1’s whereabouts on 5-17-22 leading to R1’s episode of Absence without leave (AWOL), intoxication, and injury as noted above. As a result, this allegation is SUBSTANTIATED

The following deficiencies were observed (see LIC 9099-D) and cited from the California Code of Regulations, Health and Safety Codes. A civil penalty in the amount of $500 is being issued on today's visit due to the violation resulting in serious physical injury of a resident. Failure to correct the deficiency may result in additional civil penalties. At the time of the complaint visit, the issuance of a Civil Penalty was still being determined and the licensee was informed that a civil penalty might be assessed based on Health and Safety Code § 1569.49

{Cont. on 9099C}

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 27-AS-20220520111216
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: 08/22/2022
NARRATIVE
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Allegation #2: Facility failed to notify law enforcement in a timely manner

Based on interviews conducted and record reviews as noted above, it was determined that R1 eloped from facility on 5-17-22. Incident report dated 5-18-22 indicated facility staff noticed resident missing at approximately 4:45pm on 5-17-22, and were not aware of R1’s whereabouts. Based on police report reviewed, a report from facility staff was made at 7:02pm on 5-17-22 to police department to report missing resident. Interviews also revealed that R1’s responsible party member did not observe resident in his room at approximately 2:30pm during a visit on 5-17-22. Facility’s missing resident policy reviewed and noted on R1’s needs and service plan states law enforcement are to be notified within 30 minutes should resident not be located. Based on interviews and record reviews, it is determined that law enforcement was notified outside the 30-minute window, therefore this allegation is SUBSTANTIATED.

Allegation #3: Facility failed to report to responsible party that resident had left unattended

Based on interviews conducted and record reviews as noted above, it was determined that R1 eloped from facility on 5-17-22. Incident report dated 5-18-22, states at 5:50pm a member of R1’s family called facility regarding R1’s missing status. Incident report further states police were called with no time mentioned. An additional statement on the incident report states a family member of R1 was at facility and notified that R1 was at local hospital. Incident report did not state power of attorney for R1 was notified by facility of R1’s initial missing status. Document review indicates name of power of attorney for R1. This individual was not indicated on the incident report as notified by facility due to R1’s missing status. Additional interviews indicate responsible party for R1 was not notified of R1's missing and inability to locate and did not receive a written notice of incident. Based on record reviews and interviews, it is determined that R1’s family was not notified per regulatory requirements, and this allegation is SUBSTANTIATED.

Allegation #4: Staff not properly trained on AWOL procedures.

Based on interviews conducted and record reviews as noted above, it was determined that R1 eloped from facility on 5-17-22. Interviews revealed that 4 of 4 staff members interviewed have not been trained on facility’s Absence Without Leave (AWOL) procedures. An additional interview with Administrator revealed AWOL training was not included in the staff training curriculum at the time of R1’s elopement episode on 5-17-22. Furthermore, it was determined based on interviews that facility has a history of other residents identified as elopement risks. {Cont. on 9099C}

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 27-AS-20220520111216
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: 08/22/2022
NARRATIVE
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Based on interviews and record reviews conducted it is determined that staff have not been trained properly on AWOL procedures and its associated services to residents in the event of an AWOL, posing a safety risk for residents in care. Therefore, this allegation is SUBSTANTIATED.

Based on the findings noted above, citations are issued today under Title 22, Division 6, Chapter 8 and noted on the LIC 9099D. In addition, an immediate civil penalty is issued as described under the allegation: Neglect/ lack of care and supervision resulted in resident going AWOL and sustaining an injury.

An exit interview was conducted with Belinda Guzman via phone and a copy of this report was left with Belinda. Appeal rights provided.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 27-AS-20220520111216
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: 08/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/23/2022
Section Cited
HSC
1569.312(d)
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 Basic Service Requirements. Every facility required to be licensed under this chapter shall provide at least the following basic services: (d) Being aware of the resident's general whereabouts… This requirement was not met as evidenced by:
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Licensee and designee(s) will read regulation 1569.312(d) and submit a signed declaration of understanding to LPA by POC due date.
Licensee will submit plan on how facility staff will ensure knowledge of residents whereabouts and submit plan to LPA by POC due date.
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Based on interview and record review, Licensee did not ensure facility’s knowledge of R1’s whereabouts on 5-17-22 leading to an elopement episode, intoxication, and head injury to R1. This posed an immediate health, safety, and resident rights risk to resident in care. .An immeidate civil penalty in the amount of $500 is being issued on today's visit due to the violation resulting in serious physical injury of a resident. Additional civil penalty may be assessed upon further department review.
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Licensee will conduct staff training on elopement risks and procedures and submit training scheduled date to LPA by POC due date. Training to be completed no later than 2 weeks from citation issuance date. Proof training to be sent to LPA prior to citation clearance.
Type A
08/23/2022
Section Cited
CCR
87405(b)
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Administrator-Qualificiations. (b) The administrator of a facility or facilities shall have the responsibility and authority to carry out the policies of the licensee. This requirement was not met as evidenced by:
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Licensee will submit a plan to ensure Administrator and facility staff will follow elopement policy as applicable to warranted facility events.

Licensee will submit a signed declaration that elopement policy will be followed as applicable
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Based on record review and interview, Administrator did not ensure licensee’s elopement policy of notifying police within 30 minutes of R1s elopement and inability to locate. This posed an immediate health and safety risk to resident in care.
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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 KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 27-AS-20220520111216
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: 08/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/23/2022
Section Cited
CCR
87405(h)(5)
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Administrator -Qualifications. (h)The administrator shall have the responsibility to: (5) Provide or ensure the provision of services to the residents with appropriate regard for the residents' physical and mental well-being and needs...This requirement was not met as evidenced by:
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Licensee will ensure completed staff training on AWOL procedures and submit proof of completed training to LPA by POC due date.
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Based on interview and record review, R1 eloped from facility without leave of absence on 5-17-22, and administrator did not ensure proper AWOL training to ensure necessary services to residents in the event of an AWOL episode. This poses an immediate health and safety risk to residents in care.
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Type B
08/31/2022
Section Cited
CCR
87211(a)(1)(D)
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Reporting Requirements. (a)Each licensee shall furnish to the licensing agency… (1)A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of… (D) Any incident which threatens the welfare, safety or health of any resident, such as…unexplained absence of any resident. This requirement was not met as evidenced by:
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Licensee will ensure completed staff training on reporting requirements and submit proof of completed training to LPA by POC due date.

Licensee will read regulation 87211 and submit a signed declaration of understanding to LPA by POC due date.
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Based on record review and interview, power of attorney for R1 was not notified in writing per regulatory requirements of R1’s elopement on 5-17-22. This posed a potential health, safety and resident rights risk to resident in care.
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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 KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 7
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
05/20/2022 and conducted by Evaluator Michael Bilger
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220520111216

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: 48DATE:
08/22/2022
UNANNOUNCEDTIME BEGAN:
10:04 AM
MET WITH:Belinda GuzmanTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Facility reported no visitors allowed due to Covid
INVESTIGATION FINDINGS:
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On 8-22-22 at 10:04am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver complaint findings for the allegation noted above. LPA met with Belinda Guzman via phone and explained the purpose of the visit. Belinda gave permission for Rosa Marrero, assistant business office manager to sign in her physical absence. During this investigation, LPA interviewed administrator and conducted a facility observation. Allegation states facility denied visitation of family member for R1 on 5-17-22. Based on interview conducted, it was determined that family member was able to enter facility in an attempt to visit R1. Based on additional interviews conducted, it was determined that facility allows visits during presence of COVID through alternative means including outside visits and window visits as appropriate. Interviews conducted did not reveal a history of facility denying visitations due to COVID. Based on facility observation on 8-5-22, it was determined that facility was following COVID protocols for visitation.

Based on interviews and observation, there is not a preponderance of evidence to conclude that facility staff are disallowing visitation due to COVID. Therefore, this allegation is UNSUBSTANTIATED.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Michael BilgerTELEPHONE: 916-862-4722
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 7 of 7